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 2018-12-04 Physician MAUREEN D. MINER, MD
Caller Phone Fax
Primary
Complaint
✔ Workers Compensation   Private Insurance   Medicare /2ndInsurance   Self- Pay
Patient’s
Name


Address 		SERRATOS, DANIEL 


93 Clark Street
Salinas, CA 93901

Claim/Policy#

WCAB#

Date of Injury

Soc Sec #
06223270 
ADJ10606432 
09/03/2016 
� 
Phone
(home/cell) 		831-905-6227  Phone
(work) 		  Birth Date 11/21/1979 


Adjuster Name


INS. Address 		Jaime Flores   

Employer Name


Address

 Wilson & Sons Trucking 


 
SCIF
P.O. Box 3171
Suisun City, CA 94585 
Phone 925-523-5704  Fax 707-646-0287  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 		Glen J. Grossman, Esq. 
ROL&M 
245 West Laurel Drive
Salinas, CA 93906 		SCIF Insured 
P.O. Box 3171
Suisun City, CA 94585
Phone 831-443-1051  Fax 831-443-6419  Phone 831-444-4766  Fax 831-214-6078 
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