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 2019-01-15 Physician MAUREEN D. MINER, MD
Caller Phone Fax
Primary
Complaint
  Workers Compensation   Private Insurance   Medicare /2ndInsurance   Self- Pay
Patient’s
Name


Address 		NEGRETE, ANN MARIE S 


883 NEAL COURT
LOS BANOS, CA
93635
Claim/Policy#

WCAB#

Date of Injury

Soc Sec #
 
 
 
543-94-9254 
Phone
(home/cell) 		408-804-3944  Phone
(work) 		  Birth Date 04/04/1972 


Adjuster Name


INS. Address 		   

Employer Name


Address

  


MEMBER ID#JQU301A55053
PRIMARY MEMBER: LUIS NEGRETE
GROUP: J23994
DOB# 04/13/1970
ISSUE DATE:12/1/2017
 
ANTHEM BLUE CROSS
P.O. BOX 60007
LOS ANGELES CA, 90060-0007
855-854-1438 PROVIDER SERVICES
 
Phone   Fax   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 		N/A
   
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