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Workers' Compensation Board

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

Submitting an EC-4 AMR Form For a Patient

Successful Submissions

When your form passes all validations, a non-editable PDF of the form will be returned to your web browser. Do not close your web browser until you receive this PDF, otherwise you will not know if your form was successfully submitted to the Board.

This is the only official copy of your EC-4 AMR form.

The first page of the form will be a confirmation by the Board that your form was successfully submitted and information about sending required copies to the insurance carrier, attorney, licensed representative and the patient.
confirmation page

You should print the form and attachments and save a copy for your records.

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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