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 2011-08-19 Physician MAUREEN D. MINER, MD
Caller Phone Fax
Primary
Complaint
✔ Workers Compensation   Private Insurance   Medicare /2ndInsurance   Self- Pay
Patient’s
Name


Address 		FALASCA, JILL 


810 CAPITOLA DRIVE
HOLLISTER, CA 95023

Claim/Policy#

WCAB#

Date of Injury

Soc Sec #
142-354025 
 
07/1995; 01/1996 
565-81-5437 
Phone
(home/cell) 		831-637-1526  Phone
(work) 		831-801-1298  Birth Date 11/28/1967 


Adjuster Name


INS. Address 		ELLEN COSMER   

Employer Name


Address

 CARDINAL AUTOMOTIVE 


 
ALLIANZ INSURANCE
P.O. BOX 7780
BURBANK, CA 91510-7780 
Phone 800-221-5490- x7211  Fax 818-260-7218  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 		STEPHEN D. SPRENKLE 


Defense Attorney
Address 		 
 
P.O. BOX 3500
SALINAS, CA 93912 		 

Phone 831-449-8011  Fax 831-449-2201  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