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 2011-08-18 Physician MAUREEN D. MINER, MD
Caller Phone Fax
Primary
Complaint		 FOOT
✔ Workers Compensation   Private Insurance   Medicare /2ndInsurance   Self- Pay
Patient’s
Name


Address 		WIANECKI, DEBORAH FOOT 


1300 CRESTVIEW
HOLLISTER, CA 95023

Claim/Policy#

WCAB#

Date of Injury

Soc Sec #
062912 
 
12/19/2005 
143-52-4062 
Phone
(home/cell) 		831-638-9389  Phone
(work) 		CELL: 415-999-5815  Birth Date 01/08/1957 


Adjuster Name


INS. Address 		JULIE FITZPATRICK   

Employer Name


Address

 COUMMUNITY HEALTH NETWORK 


 
INTERCARE INSURANCE SERVICES
P.O. BOX 1018
SACRAMENTO, CA 95812-1018
 
Phone 916-780-9734  Fax 916-781-5514  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
   
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