Skip to Content

Workers' Compensation Board

Language Assistance: (877) 632-4996 | Language Access Policy

Ancillary Medical Report (EC-4 AMR)
Web Submission Process Tutorial

Submitting an EC-4AMR Form For a Patient

Adding Billing Information

Complete section C. Billing information. You may add additional ICD9 codes by selecting the "Add Another ICD9 Code" button and as many billing rows as needed by selecting "Add Another Billing Row".
Adding ICD9 Codes Button and Adding Additional billing rows button

You may remove the last ICD9 code in the list by selecting the "Remove Last ICD9 Code" button and the last billing row by selecting "Remove Last Billing Row".

A minimum of one ICD9 code and one billing row is required information to be provided on the form.

Previous page
Next Page

Filling out the Form | Add Billing Information | Who Provided Services | Saving Patient Data | Adding Attachments | Submitting the Form | Successful Submissions | Saving the PDF | Printing the PDF | Submitting Additional Forms