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 2011-08-04 Physician MAUREEN D. MINER, MD
Caller Phone Fax
Primary
Complaint
✔ Workers Compensation   Private Insurance   Medicare /2ndInsurance   Self- Pay
Patient’s
Name


Address 		CANTISANI, CARMELA 


415 ENGLISH AVE.
MONTEREY, CA 93940

Claim/Policy#

WCAB#

Date of Injury

Soc Sec #
130878083 
 
12/22/1988 
132-44-3133 
Phone
(home/cell) 		831-250-5327  Phone
(work) 		831-236-4178/831-375-5313/FAX  Birth Date 1/1/1951 


Adjuster Name


INS. Address 		ELAINE GRECO   

Employer Name


Address

 US DEPARTMENT OF ARMY, MONTEREY, CA 


 
US DEPARTMENT OF LABOR
P.O. BOX 8300
LONDON, KY 40742-8300 
Phone 415-241-3300  Fax 800-215-4901  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