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 2017-07-21 Physician MAUREEN D. MINER, MD
Caller Phone Fax
Primary
Complaint		 RIGHT SHOULDER, CERVICAL SPINE, LEFT SHOULDER/ARM
✔ Workers Compensation   Private Insurance   Medicare /2ndInsurance   Self- Pay
Patient’s
Name


Address 		RAMIREZ, MICHELLE 


105 ROGGE ROAD
SALINAS, CA 93906

Claim/Policy#

WCAB#

Date of Injury

Soc Sec #
LB001231861 
ADJ10561042 
10/16/2015 
564-47-6878 
Phone
(home/cell) 		831-675-3136  Phone
(work) 		  Birth Date 08/04/1970 


Adjuster Name


INS. Address 		BRIAN DART   

Employer Name


Address

 WINDSOR COUNTRY DRIVE CARE CENTER, LLC 


 
ENSTAR GROUP, INC.
PO BOX 11027
ORANGE, CA 92856 
Phone 714-918-5958  Fax 714-919-5972  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 		JIM GONZALEZ, ESQ 


Defense Attorney
Address 		AMIR F. ADIL, ESQ. 
28 E. ROMIE LN.  
SALINAS, CA 93901
BRADFORD & BARTHEL, LLP 
2841 JUNCTION AVE, STE 114
SAN JOSE, CA 95134
Phone 831-422-0697  Fax 831-422-4258  Phone 408-392-8202  Fax 408-392-0903 
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