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Workers' Compensation Board

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Ancillary Medical Report (EC-4 AMR)


Overview

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 in workers' compensation, volunteer firefighter's or volunteer ambulance workers' benefit cases.

All reports are to be filed with the Workers' Compensation Board, the workers' compensation insurance carrier, self-insured employer, and if the patient is represented by an attorney or licensed representative, with such representative. If the patient is not represented, a copy must be sent to the patient.

If providing treatment and performing an ancillary service, this form should not be used. Report on one of the following forms:

  • 48 HOUR INITIAL REPORT - Prepare and submit Form C-4 or EC-4NARR, complete in all details, within 48 hours after you first render treatment.
  • To report continued treatment, use Form C-4.2 or EC-4NARR. To report permanent impairment, use Form C-4.3.
  • Ophthalmologists use form C-5, self-employed Occupational/Physical Therapists use form OT/PT-4 and Psychologists use form PS-4 for filing reports.

Features

  • Incomplete forms can be saved locally then completed and submitted through the Board's web site at a later time.
  • Template files with standard information (doctor, patient, insurance carrier) can be saved and used as a basis for web submission of future reports.
Sample EC-4 AMR adobe pdf    Please read:Form Instructions

A report for the services provided must be attached. Please read "Attachment Requirements".

Upon successful submission, the health care provider will be provided with a printable PDF version of the form to keep for their records and to be used to send required copies of EC-4 AMR and all attachments to the insurance carrier and to the patient's attorney or licensed representative if he/she has one, if not send a copy to the patient. DO NOT MAIL THIS FORM TO THE BOARD.

Web Submission Requirements