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 2012-10-05 Physician MAUREEN D. MINER, MD
Caller BRENDA @ LEARNING SERVICES Phone Fax
Primary
Complaint		 LEARNING SERVICES RESIDENT
✔ Workers Compensation   Private Insurance   Medicare /2ndInsurance   Self- Pay
Patient’s
Name


Address 		GERMANOV, EMIL 


10855 DE BRUIN WAY
GILROY, CA
95020
Claim/Policy#

WCAB#

Date of Injury

Soc Sec #
092127823 
 
10/05/2011 
XXX-XX-5374 
Phone
(home/cell) 		415-939-0782 JANET GILLEN, friend & DPOA  Phone
(work) 		  Birth Date 10/12/1948 


Adjuster Name


INS. Address 		ADJUSTERS ROTATE(based on claim #)   

Employer Name


Address

 PEACE CORP 


 
DEPARTMENT OF LABOR
P.O. BOX 8300 DISTRICT 13
LONDON, KY
40742-8300 
Phone 415-241-3300  Fax (800)215-4901  Phone   Fax  
Appt. TYPE   QME Panel   QME Re–Eval   QME
Applicant		   AME   Med legal   Consult ONLY ✔ Consult&Treat   EMG/NCS
Appt. DATE: 2012-10-18  Appt. TIME  
Interpreter required? ✔ No   Yes Agency/Language   

Referring Physician
Address 		N/A 
Case Manager

Address 		PRANDY KELLY
  LEARNING SERVICES 
Phone   Fax   Phone 408-848-4379  Fax 408-848-6509 

Applicant Attorney
Address 		N/A 


Defense Attorney
Address 		N/A 
 

 

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