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 2020-01-06 Physician MAUREEN D. MINER, MD
Caller Phone Fax
Primary
Complaint
✔ Workers Compensation   Private Insurance   Medicare /2ndInsurance   Self- Pay
Patient’s
Name


Address 		PIMENTEL, JAY 


1160 Payne Avenue
Gustine, CA 95322

Claim/Policy#

WCAB#

Date of Injury

Soc Sec #
151-CB-FKY0473-M 
ADJ11850666 
09/11/2018 
000-00-1177 
Phone
(home/cell) 		209-221-3559  Phone
(work) 		  Birth Date 04/18/1964 


Adjuster Name


INS. Address 		Reina Orozco   

Employer Name


Address

 Lloyd W. Aubry Co. Inc. 


2148 Dunn Road
Hayward, CA 94545 
Travelers Property Casualty Company of America
P.O. Box 660055
Dallas, TX 75266 
Phone 916-859-2691  Fax 866-871-9205  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 		Robert M. Smolich, Esq. 


Defense Attorney
Address 		Fred Boyd, Esq. 
Smolich & Smolich 
3200 J Street
Sacramento, CA 95816 		Laura G. Chapman & Associates 
P.O. Box 64093
Saint Paul, MN 55164-0093
Phone 916-443-2988  Fax 916-443-2675  Phone 916-638-6370  Fax 855-668-2538 
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