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 2020-01-07 Physician MAUREEN D. MINER, MD
Caller Phone Fax
Primary
Complaint
✔ Workers Compensation   Private Insurance   Medicare /2ndInsurance   Self- Pay
Patient’s
Name


Address 		VERMILYER, WILLIAM (2019 CASE) 


730 FLINT ROAD
SAN JUAN BAUTISTA, CA
95045
Claim/Policy#

WCAB#

Date of Injury

Soc Sec #
19-125563 
 
11/26/2019 
557-85-8880 
Phone
(home/cell) 		831-636-4647  Phone
(work) 		  Birth Date 06/13/1969 


Adjuster Name


INS. Address 		DANIEL CRAIG   

Employer Name


Address

  


 
INTERCARE HOLDINGS INSURANCE SERVICES
P.O. BOX 579
ROSEVILLE, CA
95661 
Phone 916-677-2514  Fax 916-781-5528  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
email vermylierwb@co.monterey.ca.us   
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