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 2019-05-16 Physician MAUREEN D. MINER, MD
Caller Phone Fax
Primary
Complaint
✔ Workers Compensation   Private Insurance   Medicare /2ndInsurance   Self- Pay
Patient’s
Name


Address 		LORCH, LYNNETTE 


26053 Sales Creek Road
Clovis, CA 93619

Claim/Policy#

WCAB#

Date of Injury

Soc Sec #
18022124 
ADJ12013748 
CT 09/29/2018 
 
Phone
(home/cell) 		559-297-9596  Phone
(work) 		  Birth Date 07/19/1963 


Adjuster Name


INS. Address 		Cynthia Valderrama   

Employer Name


Address

 The Permanente Medical Group 


2500 Merced Street
San Leandro, CA 94578 
Athens Administrators
P.O. Box 696
Concord, CA 94522 
Phone 925-826-1207  Fax 925-887-6662  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 		Dennis A. Popalardo, Esq. 


Defense Attorney
Address 		Ronald Neach, Esq. 
Boxer & Gerson 
Rotunda Building, 300 Frank H. Ogawa Plaza, Ste. 500
Oakland, CA 94612 		Law Offices of Ronald Neach 
P.O. Box 5278
Concord, CA 94524
Phone 510-835-8870  Fax 510-835-0415  Phone 925-837-3009  Fax  
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