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 2019-09-30 Physician MAUREEN D. MINER, MD
Caller ANA @ ATTY GREENBERGS OFFICE Phone 415-409-9900 Fax
Primary
Complaint		 CLAIM SETTLED
  Workers Compensation   Private Insurance   Medicare /2ndInsurance ✔ Self- Pay
Patient’s
Name


Address 		BROWN, SPENCER 


29536 NORTON AVE
ESCALON, CA
95320
Claim/Policy#

WCAB#

Date of Injury

Soc Sec #
 
 
03/22/2012 
569-41-2909 
Phone
(home/cell) 		209-613-3614  Phone
(work) 		  Birth Date 01/12/1975 


Adjuster Name


INS. Address 		   

Employer Name


Address

 MCM CONSTRUCTION 


6413 32ND STREET
NORTH HIGHLANDS, CA
95660 
MEDICARE & BRIDGE POINT  
Phone   Fax   Phone 916-334-1221  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
   
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