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 		KORD, RAY 


1955 AUSTIN AVENUE
CLOVIS, CA 93611

Claim/Policy#

WCAB#

Date of Injury

Soc Sec #
 
 
 
604-38-8830 
Phone
(home/cell) 		559-292-5589  Phone
(work) 		408-608-8915  Birth Date 12/21/1973 


Adjuster Name


INS. Address 		   

Employer Name


Address

 MSI 


 
ATTY JACK STEIN IS TO BE BILLED
(BLUE CROSS PPO ID XDX496A74840
POLICY GROUP 898200) 
Phone   Fax   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
   
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