Ancillary Medical Report (EC-4 AMR)
Web Submission Process Tutorial
Submitting an EC-4 AMR Form For a Patient
This form is to be used to file reports for ancillary medical services such as x-ray, pathology, anesthesia, or diagnostic services by other than the attending provider. This form should not be used to report treatment provided.
If you are providing treatment and performing ancillary service, report on one of the following forms:
- 48 Hour Initial Report – Prepare and submit form Doctor's Initial Report (C-4) or Doctor's Narrative Report (EC-4NARR)
- To report continued treatment – submit form Doctor's Progress Report (C-4.2) or Doctor's Narrative Report (EC-4NARR)
- To report permanent impairment – submit form Doctor's Report of MMI/Permanent Impairment (C-4.3)
To request authorization for special services costing over $1000.00, submit form Attending Doctor's Request for Authorization and Carrier's Response (C-4AUTH) .
You may choose to create templates which are .xml data files containing specific information that you may use for subsequent form submissions.
You will need to decide where to save these files. If all EC-4AMR forms for the doctor will be submitted from the same computer, you may choose to save them to the computer's hard drive; however, if the forms will be generated from multiple computers that are on a network, you may want to save them to a shared network drive.
Certain fields on the form are required and they are noted with a red asterisk *. Other fields may be required based on information provided. These fields are noted with a . To determine if these fields are required, either hover your mouse pointer over the or click on the .