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 2018-06-27 Physician MAUREEN D. MINER, MD
Caller Phone Fax
Primary
Complaint		 back
✔ Workers Compensation   Private Insurance   Medicare /2ndInsurance   Self- Pay
Patient’s
Name


Address 		MEDRANO, AGUSTIN 


1453 Mustang Ct.
Salinas, CA 93905

Claim/Policy#

WCAB#

Date of Injury

Soc Sec #
06351956 
ADJ11242247 
02/06/2018 
� 
Phone
(home/cell) 		831-676-6155  Phone
(work) 		  Birth Date 04/07/1988 


Adjuster Name


INS. Address 		Chris Koch   

Employer Name


Address

 Integrated Building System Inc. 


P.O. Box 862
Gilroy, CA 95021 
SCIF Insured Pleasanton
P.O. Box 3171
Suisun City, CA 94585 
Phone 714-347-4160  Fax 707-646-8575  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  SPANISH 

Referring Physician
Address 		 
Case Manager

Address
   
Phone   Fax   Phone   Fax  

Applicant Attorney
Address 		Sandra L. Rocca, Esq. 


Defense Attorney
Address 		William Wessell, Esq. 
ROL&M 
245 W. Laurel Drive
Salinas, CA 93906 		SCIF-San Jose 
P.O. Box 3171
Suisun City, CA 94585-6171
Phone 831-443-1051  Fax 831-443-6419  Phone 408-882-2000  Fax 408-882-2005 
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