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 2019-09-11 Physician MAUREEN D. MINER, MD
Caller Phone Fax
Primary
Complaint
✔ Workers Compensation   Private Insurance   Medicare /2ndInsurance   Self- Pay
Patient’s
Name


Address 		McKIBBEN, SAVALAS 


130 Cypress Street
Redwood City, CA 94061

Claim/Policy#

WCAB#

Date of Injury

Soc Sec #
2010362924 
ADJ12211248 
11/09/2018 
� 
Phone
(home/cell) 		650-921-0382  Phone
(work) 		  Birth Date 05/24/1974 


Adjuster Name


INS. Address 		Karoline Atamanyuk   

Employer Name


Address

 Cornerstone Staffing Solutions 


7020 Koll Center Pkwy.
Pleasanton, CA 94566 
Zurich
P.O. Box 968002
Schaumburg, IL 60196 
Phone 916-636-5260  Fax 415-538-7150  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
  Palo Alto
panel: 2437723 
Phone   Fax   Phone   Fax  

Applicant Attorney
Address 		Peter M. Gimbel, Esq. 


Defense Attorney
Address 		Grace Morton, Esq. 
The Law Offices of Peter M. Gimbel 
503 Seaport Court, Ste. 105
Redwood City, CA 94063 		Law Offices of Thomas J. Burns 
525 Market Street, Ste. 2900
San Francisco, CA 94104
Phone 650-474-5570  Fax 650-474-5598  Phone 415-227-2300  Fax 415-227-2360 
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