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 2019-02-07 Physician MAUREEN D. MINER, MD
Caller Phone Fax
Primary
Complaint
✔ Workers Compensation   Private Insurance   Medicare /2ndInsurance   Self- Pay
Patient’s
Name


Address 		RADILLA, AGUSTIN 


2035 California Street #21
Mountain View, CA 94040

Claim/Policy#

WCAB#

Date of Injury

Soc Sec #
Y67C96440 
ADJ11736668 
CT 07/07/2017 
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Phone
(home/cell) 		650-444-4554  Phone
(work) 		  Birth Date 05/04/1959 


Adjuster Name


INS. Address 		Shannon Masvidal   

Employer Name


Address

 W.A. Call Manufacturing Company Inc. 


1710 Rogers Avenue
San Jose, Ca 95112 
The Hartford
P.O. Box 14475
Lexington, KY 40512 
Phone 866-401-9222  Fax 859-258-2235  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
  panel: 7234350

PALO ALTO 
Phone   Fax   Phone   Fax  

Applicant Attorney
Address 		Brett Johnson, Esq. 


Defense Attorney
Address 		Monique Kleinfeld, Esq. 
Law Offices of Butts & Johnson 
675 N. First Street, Suite 975
San Jose, CA 95112 		Law Offices of Melody Z. Cox 
P.O. Box 2282
Brea, CA 92822
Phone 408-293-4818  Fax 408-293-3478  Phone 714-674-1000  Fax 714-989-2154 
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