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 2020-06-08 Physician MAUREEN D. MINER, MD
Caller Phone Fax
Primary
Complaint
✔ Workers Compensation   Private Insurance   Medicare /2ndInsurance   Self- Pay
Patient’s
Name


Address 		PEREZ RODRIGUEZ, GUADALUPE 


8260 Swanston Lane
Gilroy, CA 95020

Claim/Policy#

WCAB#

Date of Injury

Soc Sec #
6773898 
AADJ12540334 
09/04/2018 
614-87-7351 
Phone
(home/cell) 		408-413-9715  Phone
(work) 		  Birth Date 02/29/1976 


Adjuster Name


INS. Address 		Jackie Novida   

Employer Name


Address

 WKS Restaurant Corporation 


 
Sedgwick
P.O. Box 619079
Roseville, CA 95661 
Phone 714-202-2018  Fax 866-548-2637  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: 2552717 
Phone   Fax   Phone   Fax  

Applicant Attorney
Address 		Robert Pave, Esq. 


Defense Attorney
Address 		David Kargozar, Esq. 
The Poeple's Law Firm 
2114 Senter Rd., Ste. 11
San Jose, CA 95112 		Kargozar & Associates 
26741 Portola Pkwy., Ste. 1E #510
Foothill Ranch, CA 92610-1763
Phone 408-642-5962  Fax 408-495-3100  Phone 714-391-4192  Fax D.Kargozar@kargozarlaw.com 
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