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 2018-07-12 Physician MAUREEN D. MINER, MD
Caller Phone Fax
Primary
Complaint		 left pinky finger
✔ Workers Compensation   Private Insurance   Medicare /2ndInsurance   Self- Pay
Patient’s
Name


Address 		ORIBELLO, FRANCIS 


229 Autrey Street
Milpitas, CA 95035

Claim/Policy#

WCAB#

Date of Injury

Soc Sec #
06280354 
ADJ11128638 
05/14/2017 
570-95-3624 
Phone
(home/cell) 		408-483-9294  Phone
(work) 		  Birth Date 5/12/1959 


Adjuster Name


INS. Address 		Linda Willat   

Employer Name


Address

 Sonoma Developmental Center 


 
SCIF
P.O. Box 3171
Suisun City, CA 94585 
Phone 707-586-5063  Fax 707-646-0284  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 1:30 pm  
Interpreter required? ✔ No   Yes Agency/Language   

Referring Physician
Address 		 
Case Manager

Address
   
Phone   Fax   Phone   Fax  

Applicant Attorney
Address 		Bo Katzakian, Esq. 


Defense Attorney
Address 		Marc Alexander, Esq. 
Law Offices Of Bo Katzakian 
3150 Almaden Expressway,Suite 147
San Jose Ca 95118 		SCIF Legal 
P.O. Box 3171
Suisun City, CA 94585
Phone 408-816-8837  Fax 408-816-7856  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