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 2014-06-30 Physician MAUREEN D. MINER, MD
Caller BLANCA FROM AA Phone 209-524-9200 Fax
Primary
Complaint		 PANEL #1631727 LEFT KNEE, BACK
✔ Workers Compensation   Private Insurance   Medicare /2ndInsurance   Self- Pay
Patient’s
Name


Address 		SORIA, JOHN 


3612 SPRUCE AVE
MODESTO, CA
95307
Claim/Policy#

WCAB#

Date of Injury

Soc Sec #
7190244223 
ADJ9218621 
05/04/2013 
552-35-8832 
Phone
(home/cell) 		209-612-5990  Phone
(work) 		  Birth Date 02/17/1975 


Adjuster Name


INS. Address 		TRINH PONCE   

Employer Name


Address

 KENTUCKY FRIED CHICKEN 


2040 WHITMORE AVE
CERES, CA 95307 
TRISTAR RISK MANAGEMENT
P.O. BOX 2805
CLINTON, IA
52733 
Phone 714-543-0700 x1385  Fax 714-245-4734  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 		GARY C. NELSON, ESQ., LAW OFFICE OF 


Defense Attorney
Address 		N/A 
421 13TH STREET 
MODESTO, CA
95354 		 

Phone 209-524-9200  Fax 209-524-9300 or 209-529-7062  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