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 2019-07-12 Physician MAUREEN D. MINER, MD
Caller Phone Fax
Primary
Complaint
✔ Workers Compensation   Private Insurance   Medicare /2ndInsurance   Self- Pay
Patient’s
Name


Address 		ORTEGA, ANDREA 


P.O. Box 988
Soledad, CA 93960

Claim/Policy#

WCAB#

Date of Injury

Soc Sec #
2017006146 
ADJ11985487 
04/08/2017 
� 
Phone
(home/cell) 		831-774-3732  Phone
(work) 		  Birth Date 11/30/1976 


Adjuster Name


INS. Address 		Carrie Dantzig   

Employer Name


Address

 Quality Farm Labor, Inc. 


P.O. Box 932
Gonzales, CA 93926 
Insurance Co. of the West Pleasanton
P.O. Box 509039
San Diego, CA 92150 
Phone 818-444-3850  Fax 925-474-2897  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 		Sandra L. Rocca, Esq. 


Defense Attorney
Address 		A.J. Driscoll, Esq. 
ROL&M 
245 West Laurel Drive
Salinas, CA 93906 		Yrulegui Roberts 
5250 N. Palm Ave., Ste 402
Fresno, CA 93704
Phone 831-443-1051  Fax 831-443-6419  Phone 559-222-0660  Fax 559-222-2880 
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