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 2019-07-19 Physician MAUREEN D. MINER, MD
Caller Phone Fax
Primary
Complaint
✔ Workers Compensation   Private Insurance   Medicare /2ndInsurance   Self- Pay
Patient’s
Name


Address 		PISCITELLO, FRANK 


2916 Hillside Drive
Burlingame, CA 94010

Claim/Policy#

WCAB#

Date of Injury

Soc Sec #
143130; 183133 
 
03/17/2014; 09/17/2018 
 
Phone
(home/cell) 		650-464-4947 (cell)  Phone
(work) 		650-344-8062 (hm)  Birth Date 03/20/1958 


Adjuster Name


INS. Address 		Lorena Cortez   

Employer Name


Address

 City & County of San Francisco 


1000 El Camino Real
Millbrae, CA 94030 
City and County of San Francisco
1 S. Van Ness Avenue
Floor 4
San Francisco, CA 94103 
Phone 415-557-4800  Fax 415-701-5884  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 		Sean Sweeney, Esq. 


Defense Attorney
Address 		 
Durard, McKenna & Borg 
2015 Pioneer Court, Suite A
San Mateo, CA 94403 		 

Phone 650-348-6741  Fax 650-348-6979  Phone   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