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 2020-07-02 Physician MAUREEN D. MINER, MD
Caller Phone Fax
Primary
Complaint
✔ Workers Compensation   Private Insurance   Medicare /2ndInsurance   Self- Pay
Patient’s
Name


Address 		CHAVEZ, ABEL 


803 Parklawn Avenue
Crows Landing, CA 95313

Claim/Policy#

WCAB#

Date of Injury

Soc Sec #
841903-WC-4A 
ADJ12807604 
10/20/2018 
550-02-7110 
Phone
(home/cell) 		209-499-7383  Phone
(work) 		  Birth Date 09/20/1947 


Adjuster Name


INS. Address 		Sang Budke   

Employer Name


Address

 San Joaquin Tomato Growers Inc. 


 
Zenith
P.O. Box 9055
Van Nuys, CA 91409 
Phone 559-449-4734  Fax 877-280-4701  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
  panel: 7314053 
Phone   Fax   Phone   Fax  

Applicant Attorney
Address 		Troy Otus, Esq. 


Defense Attorney
Address 		Darren Wong, Esq. 
Otus Law Group 
7901 Oakport Street, Ste. 4300
Oakland, CA 94621 		Chernow & Lieb Attorneys at Law 
P.O. Box 9055
Van Nuys, CA 91409
Phone 510-250-2298  Fax 510-394-0077  Phone 818-594-0102  Fax 877-280-4701 
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