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 2018-06-18 Physician MAUREEN D. MINER, MD
Caller Phone Fax
Primary
Complaint		 left knee
✔ Workers Compensation   Private Insurance   Medicare /2ndInsurance   Self- Pay
Patient’s
Name


Address 		KOOLAN, EDIBEN YOONAN 


3461 Fosberg Road
Turlock, CA 95382

Claim/Policy#

WCAB#

Date of Injury

Soc Sec #
30189234514-0001 
ADJ11216713 
12/30/2017 
 
Phone
(home/cell) 		209-427-9088  Phone
(work) 		  Birth Date 7/30/1992 


Adjuster Name


INS. Address 		Ashley Malady   

Employer Name


Address

 Abercrombie & Fitch 


3401 Dale Rd.
Modesto, CA 95356 
Sedgwick CMS
PO Box 14440
Lexington, KY 40512-4440 
Phone 951-275-5437  Fax 951-275-5499  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 		Sean F. Gleason, Esq. 


Defense Attorney
Address 		Thomas J. Cieslinski, Esq. 
Law Offices of Gleason & Camacho 
727 18Th Street
Modesto, CA 95354 		Famiglietti & Volpe 
1748 W. Katella Avenue, Ste. 209
Orange, CA 92867
Phone 209-550-2777  Fax 209-550-2785  Phone 714-221-2900  Fax 714-221-2901 
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