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 2011-06-29 Physician MAUREEN D. MINER, MD
Caller Phone Fax
Primary
Complaint
✔ Workers Compensation   Private Insurance   Medicare /2ndInsurance   Self- Pay
Patient’s
Name


Address 		KNUDSON, BARRY DOI 10-17-2005 


725 LAGUNA SECA CT.
SAN JOSE, CA
95123
Claim/Policy#

WCAB#

Date of Injury

Soc Sec #
05-000592-LP50 
 
10/17/2005 
551-39-5462 
Phone
(home/cell) 		408-225-1457  Phone
(work) 		  Birth Date 03/29/1962 


Adjuster Name


INS. Address 		LOIS PERKINS   

Employer Name


Address

 CITY OF SAN JOSE 


 
CITY OF SAN JOSE
RISK MANAGEMENT DIVISION
200 EAST SANTA CLARA STREET
SAN JOSE, CA 95113 
Phone 408-975-1408  Fax 408-292-6447-ADJ 800-362-7229/UR  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 		N/A 
Case Manager

Address 		N/A
  FAIR ISAAC (AUTH)
FAX: 949-655-3222 
Phone   Fax   Phone   Fax  

Applicant Attorney
Address 		N/A 


Defense Attorney
Address 		N/A 
 

 

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