SOUTH COUNTY PAIN & REHAB
Maureen D. Miner. M.D.
Diplomate, American Board of Physical Medicine & Rehabilitation
Diplomate, American Board of Pain Medicine
Sub-Specialty Board Certified, Spinal Cord Medicine
Qualified Medical Evaluator
 
  7091 Monterey St., Suite A
Gilroy, CA 95020
Phone: (408) 842-9296
FAX: (408) 842-6878
Date 2016-11-23 Physician MAUREEN D. MINER, MD
Caller MARGIE Phone 831-442-7232 Fax
Primary
Complaint
  Workers Compensation   Private Insurance   Medicare /2ndInsurance   Self- Pay
Patient’s
Name


Address 		VASQUEZ, NICOLAS 


30MCGOWAN CIRLCE, APT 34
SALINAS, CA 93905

Claim/Policy#

WCAB#

Date of Injury

Soc Sec #
06178262 
ADJ10426651 
3/14/2016 
637-78-0973 
Phone
(home/cell) 		831-756-5981  Phone
(work) 		  Birth Date 6/8/1990 


Adjuster Name


INS. Address 		AMBER DUN   

Employer Name


Address

 PRIME HARVEST CONTRACTING 


 
SCIF
PO BOX 3171
SUISUN CITY, CA 94585-6171 
Phone 559-433-4128  Fax 707-646-6638  Phone   Fax  
Appt. TYPE   QME Panel   QME Re–Eval   QME
Applicant		   AME   Med legal   Consult ONLY   Consult&Treat   EMG/NCS
Appt. DATE: 0000-00-00  Appt. TIME  
Interpreter required?   No   Yes Agency/Language   

Referring Physician
Address 		 
Case Manager

Address
   
Phone   Fax   Phone   Fax  

Applicant Attorney
Address 		JEFFREY C. DITTRICH, ESQ. 


Defense Attorney
Address 		GLEN J. GROSSMAN, ESQ. 
AMOS, DITTRICH & USHANA 
1184 MONROE STREET, SUITE 6
SALINAS, CA 93906 		SCIF/LEGAL 
P.O. BOX 3171
SUISUN CITY, CA 94585
Phone 831-422-7232  Fax 831-442-7237  Phone 831-444-6030  Fax 831-444-7357 
PROVIDE MEDICAL RECORDS 3 weeks IN ADVANCE
PLEASE DO NOT SEND ORIGIANALS OR CD’S
NO SHOW FEE: $300.00
  
ACKNOWLEDGE ABOVE WITH YOUR INITIALS_____
AND FAX BACK TO OUR OFFICE. THANK YOU