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 2014-05-31 Physician MAUREEN D. MINER, MD
Caller ARTAESA Phone 510-785-800 Fax
Primary
Complaint		 PANEL # 1620705
✔ Workers Compensation   Private Insurance   Medicare /2ndInsurance   Self- Pay
Patient’s
Name


Address 		FLORES, FIDENCIA E. 


39331 WILFORD STREET
FREMONT, CA
94538
Claim/Policy#

WCAB#

Date of Injury

Soc Sec #
PZC00512030; PZC00538953 
ADJ9312698; 9738394 
03/23/2012; CT 05/23/2012 
607-39-8224 
Phone
(home/cell) 		510-695-9953  Phone
(work) 		  Birth Date 11/16/1959 


Adjuster Name


INS. Address 		OLEU BENSON   

Employer Name


Address

 FREMONT HILLS ASSISTEN LIVING AND MEMORY 


 
CRUM FORSTER ORANGE
P.O. BOX 14217
ORANGE, CA
92863 
Phone 714-244-1023  Fax 877-622-6911  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  SPANISH /  

Referring Physician
Address 		N/A 
Case Manager

Address 		N/A
   
Phone   Fax   Phone   Fax  

Applicant Attorney
Address 		T. WILLIAM HYNDMAN, ESQ., LAW OFFICES OF  


Defense Attorney
Address 		CHRISTIAN COLANTONI, ESQ., COLANTONI, COLLINS, MARREN, PHILLIPS & TULK, LLP  
24301 SOUTHLAND DRIVE, SUITE 420 
HAYWARD, CA
94545 		455 MARKET STREET SUITE 1940 
SAN FRANCISCO, CA
94105
Phone 510-785-2800  Fax 510-785-2822  Phone 415-529-5506  Fax 415-278-9744 
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