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 1969-10-01 Physician MAUREEN D. MINER, MD
Caller Phone Fax
Primary
Complaint
✔ Workers Compensation   Private Insurance   Medicare /2ndInsurance   Self- Pay
Patient’s
Name


Address 		RUVALCABA, MARIBEL 


P.O. Box 281
Seaside, CA 93955

Claim/Policy#

WCAB#

Date of Injury

Soc Sec #
WC648-C50430 
ADJ11113471 
08/20/2017 
� 
Phone
(home/cell) 		831-236-8267  Phone
(work) 		  Birth Date 02/13/1968 


Adjuster Name


INS. Address 		Christina Roth   

Employer Name


Address

 Denny's 


2137 N. Fremont Blvd.
Seaside, CA 93955 
Liberty Mutual
P.O. Box 4555
Portland, OR 97208 
Phone 503-736-8568  Fax 800-254-5578  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  Spanish 

Referring Physician
Address 		 
Case Manager

Address
  panel: 2435976 
Phone   Fax   Phone   Fax  

Applicant Attorney
Address 		Kristine Shilts, Esq. 


Defense Attorney
Address 		Timothy T. Huynh, Esq. 
ROL&M 
1035 Fifth St., Suite B
Monterey, CA 93940 		LFL&M 
2199 Norse Dr., Ste. B
Pleasant Hill, CA 94523
Phone 831-373-4725  Fax 831-373-0560  Phone 510-893-4111  Fax 510-893-0155 
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