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.

QuestionAnswer
Form NameForm Wmc 3116
Form Length2 pages
Fillable?No
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 _________________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

INSURANCE DATA:

 

 

 

 

 

 

 

 

 

 

 

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: ________________________________________

 

 

 

 

 

 

ACCIDENT INFORMATION:

 

 

 

 

 

 

 

 

 

 

 

Were you in an auto accident?

Yes

 

No:

 

 

 

 

 

 

 

 

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:

Yes

 

No If yes, when did the accident happen? _______________________

 

Will you be filing a Liability Claim:

Yes

 

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

No

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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