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Workers’ Compensation Board

New York State
Workers' Compensation Board
328 State Street  Schenectady, New York 12305
Governor David A. Paterson

Subject No. 046-275

New WCB Ancillary Medical Report Form C-4 AMR

Date: December 23, 2008

On September 16th, the Board implemented a revised set of core forms (Subject Number 046-250), including changes and additions to the C-4 family. Since the release of these forms, providers of ancillary services have requested a mechanism to report non-treatment services using a form other than Form C-4. Based on these comments, the Board created Form C-4 AMR (Ancillary Medical Report).

This new form can be used to report ancillary medical services such as radiology, pathology and diagnostic services rendered by other than the attending provider. The report of services is attached to Form C-4 AMR when submitted. Do not use this new form to report treatment provided.

Providers who provide both treatment and ancillary services should continue to report all services together on the new Forms C-4 or C-4.2.

To ensure that claimants' benefits are not delayed and that payment for treatments and services is timely, all C-4 forms should be filed with both the Board and the insurance carrier as soon as possible after treatments or services are rendered.

To obtain new Form C-4 AMR please visit the Board's website at:

Any questions regarding these matters should be referred to the Office of General Counsel at 518-486-9564.


Zachary S. Weiss