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 2020-09-23 Physician MAUREEN D. MINER, MD
Caller Phone Fax
Primary
Complaint
✔ Workers Compensation   Private Insurance   Medicare /2ndInsurance   Self- Pay
Patient’s
Name


Address 		MOTA, JUANA 


HC 67 Box 1368
Big Sur, CA 93920

Claim/Policy#

WCAB#

Date of Injury

Soc Sec #
2773637-1 
ADJ13400165 
09/20/2017 
XXX-XX-XXXX 
Phone
(home/cell) 		559-98-6934  Phone
(work) 		  Birth Date 05/05/1965 


Adjuster Name


INS. Address 		Megan Volek   

Employer Name


Address

 Post Ranch Inn 


7900 Highway 1
Big Sur, CA 93920 
AmTrust Irvine
P.O Box 89404
Cleveland, OH 44101 
Phone 844-601-7760  Fax 216-643-5500  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  Spanish 

Referring Physician
Address 		 
Case Manager

Address
  PANEL: 7357506 
Phone   Fax   Phone   Fax  

Applicant Attorney
Address 		Sandra L. Rocca, Esq. 


Defense Attorney
Address 		Richard T. Foley, Esq 
ROL&M 
245 W. Laurel Dr.
Salinas, CA 93906 		Hanna Brophy Salinas 
P.O Box 12488
Oakland, CA 94604
Phone 831-443-1051  Fax 831-784-8355  Phone 415-543-9110  Fax 831-443-8224 
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