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 2020-09-15 Physician MAUREEN D. MINER, MD
Caller Phone Fax
Primary
Complaint
✔ Workers Compensation   Private Insurance   Medicare /2ndInsurance   Self- Pay
Patient’s
Name


Address 		MONTES, SUSAN --- SHOULDERS 


760 RUCKER AVE
GILROY, CA
95020
Claim/Policy#

WCAB#

Date of Injury

Soc Sec #
9000513889-001 
 
7/27/2003 
546-23-7453 
Phone
(home/cell) 		408-221-2355   Phone
(work) 		  Birth Date 01/21/1957 


Adjuster Name


INS. Address 		CLAUDIA LAMONDO   

Employer Name


Address

  


 
BROADSPIRE  
Phone 714-579-8167  Fax 866-7804075  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 		DEBRA STRUNK, ESQ, @ ROBBINS & STRUNK 


Defense Attorney
Address 		 
7459 MONTEREY, STREET SUTE A 
GILROY, CA
95020 		 

Phone 408-848-1113  Fax 408-848-8303  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