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 2011-06-03 Physician MAUREEN D. MINER, MD
Caller Phone Fax
Primary
Complaint
  Workers Compensation   Private Insurance ✔ Medicare /2ndInsurance   Self- Pay
Patient’s
Name


Address 		FISHER, DOROTHY 


154 MARKS DRIVE
HOLLISTER, CA 95023

Claim/Policy#

WCAB#

Date of Injury

Soc Sec #
 
 
 
566-34-4046 
Phone
(home/cell) 		831-637-2326  Phone
(work) 		  Birth Date 11/15/1929 


Adjuster Name


INS. Address 		   

Employer Name


Address

  


 
1. MEDICARE
2. BLUE CROSS 
Phone   Fax   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 		DR. PETER COELHO 
Case Manager

Address
930 SUNSET DR., BLDG 1, STE. A
HOLLISTER, CA 95023 		  
Phone 831-637-5873  Fax   Phone   Fax  

Applicant Attorney
Address 		 


Defense Attorney
Address 		 
 

 

Phone   Fax   Phone   Fax  
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