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 2019-04-04 Physician MAUREEN D. MINER, MD
Caller Phone Fax
Primary
Complaint
✔ Workers Compensation   Private Insurance   Medicare /2ndInsurance   Self- Pay
Patient’s
Name


Address 		VAZQUEZ, AVIGAIL 


1455 Tecopa Way
Salinas, CA 93905

Claim/Policy#

WCAB#

Date of Injury

Soc Sec #
33091968 
ADJ11340531 
09/10/2017 
� 
Phone
(home/cell) 		408-337-7591  Phone
(work) 		  Birth Date 06/16/1960 


Adjuster Name


INS. Address 		Eileen Quinones   

Employer Name


Address

 Naturipe Berry Growers, Inc. 


 
Berkshire Hathaway
P.O. Box 881716
San Francisco, CA 94188 
Phone 800-661-6029  Fax 415-675-5469  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 		Rachelle Parks, Esq. 


Defense Attorney
Address 		Darla Bava, Esq. 
Rachelle Parks Monterey 
444 Pearl Street, Ste. E-4
Monterey, CA 93940 		Haworth, Bradshaw, Shallknecht & Barbar, Inc. 
344 Salinas Street, Ste. 106
Salinas, CA 93901
Phone 831-657-9030  Fax 866-735-0986  Phone 831-443-4400  Fax 831-443-5539 
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