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 2018-08-13 Physician MAUREEN D. MINER, MD
Caller Phone Fax
Primary
Complaint		 ankle, foot, toe, L leg
✔ Workers Compensation   Private Insurance   Medicare /2ndInsurance   Self- Pay
Patient’s
Name


Address 		AGUILAR, ADOLFO 


17640 NW Cornell, Apt. 3
Beaverton, OR 97006

Claim/Policy#

WCAB#

Date of Injury

Soc Sec #
FBP0304 
 
01/21/2018 
 
Phone
(home/cell) 		408-794-9994  Phone
(work) 		  Birth Date 06/01/1970 


Adjuster Name


INS. Address 		Alicia Jimenez   

Employer Name


Address

 Equity Residential A Maryland 


 
Travelers Walnut Creek
P.O. Box 13089
Sacramento, CA 95813 
Phone 925-945-4000  Fax 877-634-3710  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 		Jennifer Scotto, Esq. 


Defense Attorney
Address 		Dennis Brewer, Esq. 
Vincent Scotto San mateo 
700 S. Claremont St., Ste. 101
San Mateo, CA 94402 		Law Office of W. Dennis Brewer 
P.O. Box 1194
Woodacre, CA 94973
Phone 650-401-6161  Fax 650-401-6129  Phone 415-435-0175  Fax 415-435-0176 
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