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 2011-08-05 Physician MAUREEN D. MINER, MD
Caller Phone Fax
Primary
Complaint
✔ Workers Compensation   Private Insurance   Medicare /2ndInsurance   Self- Pay
Patient’s
Name


Address 		PARKS, RALPH 


200 BURNETT AVE, #8
MORGAN HILL, CA 95037

Claim/Policy#

WCAB#

Date of Injury

Soc Sec #
AD-05-05-00052 
 
1/15/2005 
469-50-0707 
Phone
(home/cell) 		408-779-6682  Phone
(work) 		408-210-0426 /CELL  Birth Date 7/2/1946 


Adjuster Name


INS. Address 		TANG HER   

Employer Name


Address

 GILROY TOYOTA 


 
CORVEL
PO BOX 277550
SACRAMENTO, CA 95827 
Phone 916-379-5560  Fax 866-430-47203  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
  BILLING INQUIRIES: 916-414-4500 
Phone   Fax   Phone   Fax  

Applicant Attorney
Address 		TODD MCFARREN, ESQ. 


Defense Attorney
Address 		 
 
119 E. BEACH ST
WATSONVILLE, CA 95076 		 

Phone 831-728-4200  Fax 831-728-5789  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