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 2020-01-17 Physician MAUREEN D. MINER, MD
Caller Phone Fax
Primary
Complaint
✔ Workers Compensation   Private Insurance   Medicare /2ndInsurance   Self- Pay
Patient’s
Name


Address 		DIAZ, HERIBERTO (EDDY) 


5639 Arcadia Circle
Discovery Bay, CA 94505

Claim/Policy#

WCAB#

Date of Injury

Soc Sec #
BER1900101 
ADJ12548950 
CT 03/16/2019 
XXX-XX-9557 
Phone
(home/cell) 		925-864-0515  Phone
(work) 		  Birth Date 10/16/1980 


Adjuster Name


INS. Address 		Lilia Newton   

Employer Name


Address

 City of Berkeley Police Department 


1 Sproul Hall
Berkeley, CA 94720 
Innovative Claims Solutions, Inc.
P.O. Box 5128
San Ramon, CA 94583 
Phone 925-327-8050  Fax 925-327-8078  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 		Seth Merrick, Esq. 


Defense Attorney
Address 		Thomas A. Richard, Esq 
Rains Lucia Stern, PC 
220 Montgomery Street, 15Th Floor
San Francisco, CA 94104 		Richard, Thorson,Graves & Royer, LLP 
180 Grand Avenue, Suite 300
Oakland, CA 94612
Phone 415-341-9341  Fax 415-780-9929  Phone 510-338-3166  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