Elizabeth Holt

 
 Date 18-05-05 
 Occupational Health A Northbay Affiliate 
 Page 
 I 
 1101 B. Gale Wilson Blvd, Suite 203 
 Fairfield, CA 94533 
 (707) xxx-4600, Fax: (707) xxx-4601 
 Work Status Summary 
 Company: 
 Chevy's- FF 
 Employee: 
 Florentino Mejia-Gallego 
 1320 Travis Blvd 
 1324 Travio Ct. 
 Fairfield, CA Random_5_digit_number 
 Apt. #1 
 Fairfield, CA Random_5_digit_number 
 Attention: 
 Kevin Murphy 
 Ident: 
 xxx-xx-8092 
 DOB: 85-11-20
 Telephone: 
 (707) xxx-8374 
 Fax: 
 (707) xxx-2134 
 Department: 
 Job Title: 
 Provider: 
 Kitchens, Charles MD 
 Phone: (707) xxx-5182 
 Visit Date: 
 18-08-10 Time In: 9:51AM Out: 10:45AM 
 Purpose: 
 Worker's Comp Follow Up 
 Insurance Information 
 GALLAGHER BASSETT 
 Contact: 
 P.O. BOX 10869
 Telephone: 714-10869 Ext: 
 ANAHEIM (South), CA 92825-10869 
 Fax: 
 714-9310869 
 Presenting Problem 
 Date of Injury: 
 22-07-12
 Case Number: 2012-10869
 Claim Number:002406010869WC01 
 Diagnosis 

