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 2013-04-10 Physician MAUREEN D. MINER, MD
Caller Phone Fax
Primary
Complaint
  Workers Compensation   Private Insurance ✔ Medicare /2ndInsurance   Self- Pay
Patient’s
Name


Address 		HUNT, GAIL N 


11440 COLUMBET AVE
GILROY, CA
95020
Claim/Policy#

WCAB#

Date of Injury

Soc Sec #
 
 
 
XXX-XX-4228 
Phone
(home/cell) 		408-824-0788 / 408-683-2426  Phone
(work) 		  Birth Date 01/11/1942 


Adjuster Name


INS. Address 		   

Employer Name


Address

 RETIRED 


 
MEDICARE A & B #359344228A

AARP MEDICARE SUPPLEMENTAL UHC
#09821296912 PLAN F
P.O. BOX 740819, ATLANTA, GA 30374-0819 
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 		SAMUEL WENDONG WU, M.D. 
Case Manager

Address
7880 WREN AVE., SUTIE D 143
GILROY, CA 95020 		  
Phone 408-846-1800  Fax 408-846-1995  Phone   Fax  

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