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 2011-08-12 Physician MAUREEN D. MINER, MD
Caller Phone Fax
Primary
Complaint		 RIGHT UPPER EXTREMITY
✔ Workers Compensation   Private Insurance   Medicare /2ndInsurance   Self- Pay
Patient’s
Name


Address 		WELLS, SUSAN 


66 HERITAGE VILLAGE LANE
CAMPBELL, CA 95028

Claim/Policy#

WCAB#

Date of Injury

Soc Sec #
10W0172 
 
2/23/2010 
547-02-9391 
Phone
(home/cell) 		408-310-9681  Phone
(work) 		  Birth Date 1/20/1954 


Adjuster Name


INS. Address 		S. GALE SIKES   

Employer Name


Address

 PG&E 


 
PG&E
P.O. BOX 7779
SAN FRANCISCO, CA 94120-7779 
Phone 415-973-1243  Fax 415-973-7828  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