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 2020-08-04 Physician MAUREEN D. MINER, MD
Caller Phone Fax
Primary
Complaint
✔ Workers Compensation   Private Insurance   Medicare /2ndInsurance   Self- Pay
Patient’s
Name


Address 		MENDOZA, MIGUEL 


5433 W. Los Altos Avenue
Fresno, CA 93722-3608

Claim/Policy#

WCAB#

Date of Injury

Soc Sec #
E3382002 
 
08/01/2018 
623-82-4928 
Phone
(home/cell) 		916-236-9591  Phone
(work) 		  Birth Date 10/29/1970 


Adjuster Name


INS. Address 		Sharise Woods   

Employer Name


Address

 Granite Construction 


2716 S. Granite Ct.
Fresno, CA 93706-5455 
CNA Insurance
P.O. Box 8317
Chicago, IL 60680 
Phone 714-674-5680  Fax 877-371-5122  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: 2572943 
Phone   Fax   Phone   Fax  

Applicant Attorney
Address 		 


Defense Attorney
Address 		 
 

 

Phone   Fax   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