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 2020-07-01 Physician MAUREEN D. MINER, MD
Caller Phone Fax
Primary
Complaint
✔ Workers Compensation   Private Insurance   Medicare /2ndInsurance   Self- Pay
Patient’s
Name


Address 		MADRIGAL, VERONICA 


55 Arista Lane, Apt. D
Watsonville, CA 95076

Claim/Policy#

WCAB#

Date of Injury

Soc Sec #
33116013 
 
08/21/2019 
618-45-6637 
Phone
(home/cell) 		831-254-4706  Phone
(work) 		  Birth Date 01/01/1975 


Adjuster Name


INS. Address 		Karina Rosas   

Employer Name


Address

 George Diaz Rancho Alitos, LLC 


P.O. Box 40
Watsonville, CA 95077 
Cypress Insurance Company
P.O. Box 881716
San Francisco, CA 94188 
Phone 800-661-6029  Fax 415-675-5469  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: 7328467 
Phone   Fax   Phone   Fax  

Applicant Attorney
Address 		James Kim, Esq. 


Defense Attorney
Address 		 
The Peoples Law Firm 
2114 Senter Road, Ste. 11
San Jose, CA 95112 		 

Phone 408-642-5962  Fax 408-495-3100  Phone   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