Form Wmc 3116 PDF Details

If you are a business owner, you may be wondering what Form Wmc 3116 is. This form is used to report payments made for workers' compensation insurance. You will need to file this form annually with the California Workers' Compensation Insurance Rating Bureau. There are several ways to submit the form, and you can find more information on the bureau's website. Filing this form on time is important, as it helps ensure that your business meets all of the requirements for workers' compensation insurance.

This basic report will let you ascertain how long it will require you to fill out form wmc 3116, the number of pages it has, and a handful of additional specific details about the PDF.

Form NameForm Wmc 3116
Form Length2 pages
Fillable fields0
Avg. time to fill out30 sec
Other namesGuarantor, wake med outpatient rehab, Guarantors, rehab update forms

Form Preview Example

Outpatient Rehab Registration Form


Date of Initial Appointment: __________________________________







Patient Name: ____________________________________________

Date of Birth: _______________


SS#: ______-_____-______ Age: _______

Race: ______________ Sex: _____

Marital Status: ____________


Home Phone: (___) ___________

Cell Phone: (___) ___________

Other Contact number: (___) ___________


Email address (Optional): ________________________________________






Mailing Address: ________________________________

City: _________________

State: _____

Zip: ______


County: ________________________











Physical Living Address (If different from above): ____________________

City: __________ State: ___

Zip: ______


County: ________________________













Patient Employee: ___________________________________ Employer Phone: ____________________________


Employer Address: _____________________________

City: _________________

State: _____

Zip: _______














Emergency Contact Person












Primary: __________________________________________

Relationship: _____________________________


Phone: 1) Home: __________________

2) Work: __________________

3) Cell or other: __________________


Secondary Emergency Contact Person: ________________________ Relationship: _______________________


Phone: 1) Home: __________________

2) Work: __________________

3) Cell or other: __________________


Preferred language for health care information _________________________________________________________


























NOTE: You MUST bring valid insurance card to have claim submitted to Insurance Company.



Insurance Name: _______________________________________________________________________________


Subscriber Employer (if different from above): ________________________________________________________


Subscriber's Name: _____________________

Date of Birth: __________

Relationship to patient: ____________















If not on insurance card:













Policy #: ______________________________

Group #: _________________________



Claims mailing address: __________________________________________________________________________


Phone number for customer service: ______________________________________

Date of Birth: _____________


Guarantor Name, if other than patient: __________________________________

Guarantor's SS#: ______________


Guarantor's Address: ____________________________________________________________________________


Relationship to patient: ___________________________________________________________________________


Guarantor's Employer: ___________________________________________________________________________




Reason for your visit/diagnoses: ____________________________________________________________________


When did you start having these symptoms? __________________________________________________________



Referring Doctor's Name: _________________________________

Doctor's Phone Number: _________________

Family Physician: ________________________________________



















Were you in an auto accident?












If yes, when and where (county or city) did the accident take place: ___________________________________


What is the name of the person responsible for the accident: ____________________________________________


What type of auto insurance does the responsible party have? __________________________________________


Did a Police or Sheriff come to the scene of the accident? ______________________________________________


Is this a work related accident:



No If yes, when did the accident happen? _______________________


Will you be filing a Liability Claim:



No If yes, please make sure this information is included in the insurance section of form.


Name of contact person for Worker's Compensation: ________________________ Phone number: ____________


Company's Name: ____________________________

Claim number for Worker's Comp: __________________





Patient's/Parent Signature: ___________________________________________

Date: __________________











Form may be thinned from Patient's File




REV. 3/13 WMC-3116

Checklist for first Outpatient Rehab Appointment:

____ 1. Completed: WakeMed Rehab Outpatient Services Intake Profile Form

____ 2. Completed: Outpatient Rehab Registration Form

____ 3. Current Insurance Card

____ 4. Photo Identification (of patient if an adult or parent/legal guardian if patient is a minor)

____ 5. If not already faxed by doctor's office, please bring your signed Physician/Doctor's Referral Form

(Date on the form must be less than 30 days from date of 1st rehab appointment)

Your physician may participate in a program that alerts them about your visit today. If your doctor has provided an

email address for this purpose, may we notify him/her of your visit today? Yes


If there is anyone other than the patient that will be responsible for calling to make appointments, scheduling inquiries or to inquire on your progress, please let us know. A medical information release form is required if you are not the parent of a minor or legal guardian.

If you have a Health Care Power of Attorney form completed, please bring a copy of the official form and the information will be placed in your file. Thank you for choosing WakeMed and we look forward to exceeding your rehab needs.

For questions about the Rehab Registration Process, please call 919-350-4626.

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