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.
Question | Answer |
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Form Name | Form Wmc 3116 |
Form Length | 2 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 30 sec |
Other names | Guarantor, wake med outpatient rehab, Guarantors, rehab update forms |
Outpatient Rehab Registration Form
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Date of Initial Appointment: __________________________________ |
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Patient Name: ____________________________________________ |
Date of Birth: _______________ |
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SS#: |
Race: ______________ Sex: _____ |
Marital Status: ____________ |
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Home Phone: (___) ___________ |
Cell Phone: (___) ___________ |
Other Contact number: (___) ___________ |
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Email address (Optional): ________________________________________ |
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Mailing Address: ________________________________ |
City: _________________ |
State: _____ |
Zip: ______ |
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County: ________________________ |
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Physical Living Address (If different from above): ____________________ |
City: __________ State: ___ |
Zip: ______ |
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County: ________________________ |
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Patient Employee: ___________________________________ Employer Phone: ____________________________ |
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Employer Address: _____________________________ |
City: _________________ |
State: _____ |
Zip: _______ |
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Emergency Contact Person |
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Primary: __________________________________________ |
Relationship: _____________________________ |
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Phone: 1) Home: __________________ |
2) Work: __________________ |
3) Cell or other: __________________ |
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Secondary Emergency Contact Person: ________________________ Relationship: _______________________ |
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Phone: 1) Home: __________________ |
2) Work: __________________ |
3) Cell or other: __________________ |
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Preferred language for health care information _________________________________________________________ |
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INSURANCE DATA: |
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NOTE: You MUST bring valid insurance card to have claim submitted to Insurance Company. |
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Insurance Name: _______________________________________________________________________________ |
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Subscriber Employer (if different from above): ________________________________________________________ |
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Subscriber's Name: _____________________ |
Date of Birth: __________ |
Relationship to patient: ____________ |
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If not on insurance card: |
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Policy #: ______________________________ |
Group #: _________________________ |
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Claims mailing address: __________________________________________________________________________ |
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Phone number for customer service: ______________________________________ |
Date of Birth: _____________ |
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Guarantor Name, if other than patient: __________________________________ |
Guarantor's SS#: ______________ |
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Guarantor's Address: ____________________________________________________________________________ |
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Relationship to patient: ___________________________________________________________________________ |
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Guarantor's Employer: ___________________________________________________________________________ |
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Reason for your visit/diagnoses: ____________________________________________________________________ |
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When did you start having these symptoms? __________________________________________________________ |
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Referring Doctor's Name: _________________________________ |
Doctor's Phone Number: _________________ |
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Family Physician: ________________________________________ |
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ACCIDENT INFORMATION: |
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Were you in an auto accident? |
Yes |
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No: |
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If yes, when and where (county or city) did the accident take place: ___________________________________ |
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What is the name of the person responsible for the accident: ____________________________________________ |
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What type of auto insurance does the responsible party have? __________________________________________ |
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Did a Police or Sheriff come to the scene of the accident? ______________________________________________ |
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Is this a work related accident: |
Yes |
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No If yes, when did the accident happen? _______________________ |
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Will you be filing a Liability Claim: |
Yes |
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No If yes, please make sure this information is included in the insurance section of form. |
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Name of contact person for Worker's Compensation: ________________________ Phone number: ____________ |
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Company's Name: ____________________________ |
Claim number for Worker's Comp: __________________ |
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Patient's/Parent Signature: ___________________________________________ |
Date: __________________ |
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Form may be thinned from Patient's File |
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REV. 3/13
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