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 1969-12-31 Physician MAUREEN D. MINER, MD
Caller Phone Fax
Primary
Complaint		 PANEL #1309859 330 RIGHT HAND INCLUDING 340 FINGERS WITH PAIN RADIATION INTO 313 RIGHT ELBOW, 842 DEPRESSION AND 880 SLEEP DISORDER AS COMPENSABLE CONSEQUENCE
✔ Workers Compensation   Private Insurance   Medicare /2ndInsurance   Self- Pay
Patient’s
Name


Address 		FRANCO, JAIME 


22388 SOUTH GARDEN AVENUE
HAYWARD, CA
94541
Claim/Policy#

WCAB#

Date of Injury

Soc Sec #
001081-001007-WC-01 
ADJ7646101 
09/21/2010 
610-18-6322 
Phone
(home/cell) 		510-670-4754  Phone
(work) 		  Birth Date 04/14/1968 


Adjuster Name


INS. Address 		KATHY LAINE   

Employer Name


Address

 LONGVIEW FIBRE CO. 


 
GALLAGHER BASSETT SERVICES
P.O. BOX 4040
SACRAMENTO, CA
95812 
Phone 916-576-8200  Fax 916-576-8206  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 		T. WILLIAM HYNDMAN ESQ., LAW OFFICES OF 


Defense Attorney
Address 		VICKI N. LINDQUIST 
24301 SOUTHLAND DRIVE, SUITE 420 
HAYWARD, CA
94545 		255 CALIFORNIA STREET, SUITE 600 
SAN FRANCISCO, CA
94111
Phone 510-785-2800  Fax 510-785-2822  Phone 415-781-6676  Fax 415-781-6823 
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