Southern Californi IMMEDIATE MEDICAL CENTER

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Theresa Williams
6 years ago
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1 , California 90723

2 , California EDEX FACT SHEET EDEX stands for Electronic Data Exchange. In 1994 Workers Compensation developed EDEX to provide electronic document filing in place of mailing forms to the state. The current system also provides several electronic case research and tracking tools. EDEX allows approved subscribers and their clients to request and receive, via electronic transmissions, summary of Workers Compensation Appeals Board cases in the State of California. EDEX enables us to insure that prior applicant Workers Compensation claims are considered as part of the patients past medical history. Enrolling in EDEX is a simple process. You just complete and sign the EDEX Client Acknowledgement of Legal Constraints Form. It will take about 1 to 2 working days to complete the registration process. Once you give the applicant a Conditional offer of Employment and the applicant has signed an Authorization and Consent to obtain information we can process the paperwork. For more information on EDEX speak with your a Client Services Representative.

3 , California Physical Federal Drug Screen Breath Alcohol Test Federal Non-Federal Hepatitis B Vaccine TB Titers

4 , California 90723

5 , California CLIENT INFORMATION SHEET Company s Name Organization Type: CORP. LLC PART INDIV Company s Name if Different/ DBA Tax I.D. Name(s) of Principals/Owners: 1. % 2. % Company s Address City State Zip Phone Number Fax Contact Person(s) Do you have any other locations? Yes No If Yes, please list: Describe what your company does: Drug Screening: Post Accident Drug Screen Yes No Temporary Modified Work: Available Yes No Number of Employees Workers Comp Carrier: Carrier Address City State Zip Phone Number Fax Policy Number Expiration Date Self-Insured: Yes No If Yes, Please Provide Claim Administrator s: Name Address City State Zip Billing Procedures: Bill Workers Comp carrier all the time? Yes No Bill Company for First Aid cases? Yes No Bill Company for review and processing? Yes No Third party injuries/customer injuries please indicate your policy by checking one of the boxes below: Employer WILL PAY entire treatment with signed authorization. Employer WILL PAY only, with signed authorization. Employer WILL NOT PAY medical provider. Other:. NOTE: 1. As per Labor Code Section , payment is due 45 days from receipt of bill. Any and all discounts are void for bills not paid 60 days after receipt. After 60 days all outstanding balances will be subject to a 15% late fee, per L.C. Section All Physicals and Drug Screens are billed once a month. Payment is expected within 30 days from date of bill and considered delinquent after 60 days. After 90 days, a late charge of 1.5% a month will be assessed to all unpaid balances. 3. The undersigned understands that by accepting direct payment from employer, the Medical Group is in fact extending credit to company. If bills are paid directly by company, the undersigned hereby authorizes Medical Group to run business profile background check at account inception date and at other dates, if deemed appropriate. Please accept verbal authorizations in lieu of written for medical treatment from the following contacts only, in order to expedite medical treatment:,, Name and Title of Authorized Person Signing Form Date a Representative Date

6 , California WORKERS COMPENSATION PREFERRED PROVIDER ORGANIZATIONS a is on the panels of the following Preferred Provider Organizations & Medical Provider Networks. Should your company belong to a panel that is not on this list, please contact your Client Services Representative. 1 A.I.G./First Health 42 First Health / Coventry 83 Nova Casualty 2 ACE USA 43 Focus Concentra 84 Novaeon 3 Alaska National / Concentra 44 Foundation Health 85 Octagon Risk / First Health / 4 Alexis Risk / Corvel 45 Frank Gates Acclaim / Concentra 86 One Source / CCN 5 Align Network 46 Fremont Compensation / Concentra 87 OUCH / Health Care Compare 6 American Commercial Claims Admin 47 GAB Robins / Concentra 88 Pacific Rim / Metra Comp 7 Anthem Blue Cross 48 Gallagher Bassett / Concentra 89 Pincale Risk Management / 8 Applied Underwriters 49 Gates Mc Donald / Concentra 90 PPO Alliance / First Health / 9 Argonaut Insurance / Corvel 50 Golden Eagle 91 Preferred Employers Direct 10 Athens / Concentra 51 Harbor Health Systems 92 Preferred Health Net 11 Avizent 52 Hartford / First Health 93 Public Service Mutual 12 Barret Business Services, Inc. (BBSI) 53 Health Care Compare (OUCH) 94 Promesa Health 13 Beech Street 54 Health Net / HCO 95 Quest 4 Care 14 Berkshire Hathaway 55 Helmsman Management 96 Ralphs 15 Blue Cross of California 56 Hertz Claim / Beech Street 97 Redwood Fire & Casualty 16 Broadspire / Concentra 57 HIH America / Concentra 98 Reliance / United Pac / First 17 Bunch & Associates / Concentra 58 Industrial Indemnity 99 Republic Indemnity / Blue Cross 18 California Foundation for Medical Care 59 Insurance Company of the West 100 Rising Medical Solution 19 California Indemnity 60 Intercare 101 Safeco / Concetra 20 Cambridge Ins. / Concentra 61 Interplan 102 Safeway / MPN 21 Care America 62 Intracorp / First Health / CCN 103 Seabright Insurance 22 Chartis 63 Keenan & Associates 104 Sedgwick / First health / CCN 23 CIGA / Coventry 64 Kemper Insurance / Concentra 105 Sentry Ins./ First Heath 24 CIGNA / First Health 65 K-Med 106 a Edison 25 CNA / Concentra 66 Liberty Mutual Insurance / Blue Cross/ First Health 107 a Gas 26 Comp America / Health Net (HCO) 67 Lindsey Morden Insurance (GENEX) 108 a Risk 27 Comp Care 68 LWP Claims / Concentra 109 Sparta Ins. / Rockport 28 Concentra / Focus / Coventry 69 Macy's / Medex 110 Specialty Risk Services 29 Corvel Health Care (Comp. HCO) 70 Magna Carta Company 111 State Comp Insurance Fund 30 Coventry 71 Majestic Insurance / Blue Cross 112 Travelers / Concentra 31 Crawford / Concentra 72 Matrix Absence Mgt. 113 Travelers TravNet MPN 32 Crum & Forester / Concentra 73 Med Risk 114 Tristar Risk Management 33 Cypress 74 Medex (HCO) 115 Tru Care 34 Employers Compensation 75 MedFocus 116 Unicare / Blue Cross 35 Employers Direct Ins. Company 76 Medi Team / Corvel 117 United Health Care / Metra 36 ESIS / Concentra 77 Medview Services 118 USA Casualty / CCN 37 Everest National 78 Metra Health / Metra Comp 119 Vons/ Safeway 38 Farmers / Corvel 79 National Health Quest 120 Wasau Insurance / First Health 39 FHP / Great States 80 Network By Design 121 Well Comp / SCRMA 40 Fireman's Fund / Concentra 81 Network Synergy - P.T. Network 122 York 41 First Comp Ins 82 Northbrook / Comp Alliance 123 Zurich Insurance * This list is being expanded constantly as new contracts are signed. 06/08/2017

7 , California 90723

Bulletin No March 8, 2013

Bulletin No March 8, 2013 WCIRB Bulletin Bulletin No. 2013-03 March 8, 2013 525 Market Street, Suite 800 San Francisco, CA 94105-2767 415.777.0777 Fax 415.778.7007 www.wcirb.com wcirb@wcirb.com 2013 Annual Meeting Notice and Agenda