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 2020-07-10 Physician MAUREEN D. MINER, MD
Caller Phone Fax
Primary
Complaint
✔ Workers Compensation   Private Insurance   Medicare /2ndInsurance   Self- Pay
Patient’s
Name


Address 		GOOLSBY, CALVIN 


1561 AIMWELL AVENUE
SACRAMENTO, CA 95835

Claim/Policy#

WCAB#

Date of Injury

Soc Sec #
011858004331WC01 
SJO 202708 
04/21/1998 
409-96-8581 
Phone
(home/cell) 		916-928-0442  Phone
(work) 		CELL: 916-205-8904  Birth Date 07/23/1954 


Adjuster Name


INS. Address 		   

Employer Name


Address

 NORTHRAP GRUMMNAN 


 
GALLAGHER & BASSETT
P.O. BOX 255397
SACRAMENTO, CA 95065

888-386-3243 UR 
Phone 951-893-4029  Fax 866-868-0794  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 		DAVID MOYLES 


Defense Attorney
Address 		 
 
111 W. ST JOHN ST. 11TH FLOOR
SAN JOSE, CA 95115 		 

Phone 408-298-5678  Fax 408-298-7503  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