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 2014-09-30 Physician MAUREEN D. MINER, MD
Caller MICHAEL/ADJUSTER Phone Fax
Primary
Complaint
✔ Workers Compensation   Private Insurance   Medicare /2ndInsurance   Self- Pay
Patient’s
Name


Address 		CORTES, EDGARDO 


1233 SAN MIGUEL CANYON ROAD
WASTONVILLE, CA 95076

Claim/Policy#

WCAB#

Date of Injury

Soc Sec #
33032892 
ADJ9748247 
09/12/2012 
643-23-1152 
Phone
(home/cell) 		831-722-0769  Phone
(work) 		  Birth Date 11/29/1977 


Adjuster Name


INS. Address 		Lauren Menz   

Employer Name


Address

 WHITLOW CONCRETE, INC. 


 
BERKSHIRE HATHAWAY HOMESTATE COMPANIES
P.O. BOX 881716
SAN FRANCISCO, CA 94188 
Phone 800-661-6029 x7718  Fax 415-675-5469  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 		Nicholas Dilles, Esq. 


Defense Attorney
Address 		Raul Martinez, Esq. 
Sprenkle & Georgiou, LLP 
P.O. BOX 3500
SALINAS, CA 93912 		LFL&M 
One Capitol Mall, Ste. 400
Sacramento, CA 95814
Phone 831-449-8011  Fax 831-449-2201  Phone 408-286-8801  Fax 408-286-1935 
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