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 2019-05-10 Physician MAUREEN D. MINER, MD
Caller Phone Fax
Primary
Complaint
✔ Workers Compensation   Private Insurance   Medicare /2ndInsurance   Self- Pay
Patient’s
Name


Address 		LOPEZ, SERGIO 


25 Camino De Travesia
Carmel Valley, CA 93924

Claim/Policy#

WCAB#

Date of Injury

Soc Sec #
6822625 
ADJ11833069 
08/01/2018 
 
Phone
(home/cell) 		831-277-3673  Phone
(work) 		  Birth Date 12/22/1999 


Adjuster Name


INS. Address 		Marquitta Woods   

Employer Name


Address

 SJ Ferrante Builders, Inc. 


P.O. Box 52
Monterey, CA 93942 
Benchmark
430 N. Vineyard Avenue, Ste. 230
Ontario, CA 91764 
Phone 800-362-5198  Fax   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 		Kristine L. Henderson, Esq. 


Defense Attorney
Address 		Jeremy Crowley, Esq. 
ROL&M 
1035 Fifth Street, Ste. B
Monterey, CA 93940 		Coleman Chavez  
1731 E. Roseville Pkwy., Ste. 200
Roseville, CA 95661
Phone 831-373-4725  Fax 831-373-0560  Phone 916-787-2300  Fax 916-787-2301 
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