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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. 046-312

New Form EC-4 AMR, Ancillary Medical Report, Now
Available For Electronic Submission

Date: April 24, 2009

One of the goals of the Workers' Compensation Reform initiative is to enhance the service the Board provides to injured workers, employers and stakeholders. A critical element of this effort is the redesign of forms the Board uses to gather information about a claim. The goal of the forms redesign effort is to develop more user-friendly forms while collecting additional information needed to more quickly process and resolve claims, including claims that have been controverted.

On December 23, 2008, following requests from providers of ancillary services to report non-treatment services using a form other than Form C-4, the Board issued Form C-4 AMR, Ancillary Medical Report (see Subject No. 046-275). We are pleased to announce today that the Board has released Form EC-4 AMR, an electronic version of Form C-4 AMR, which can be completed and submitted on-line at the Board's website ( With Form EC-4 AMR, standard information can be saved and used as a basis for future reports. As with C-4 AMR, the doctor must include a report of the services provided as an attachment with the form. Form EC-4 AMR may be used to report non-treatment services such as radiology, anesthesia, pathology and diagnostic services by other than the attending provider. This form may not be used to report treatment provided. Providers who provide both treatment and ancillary services should continue to report all services together on Forms C-4 or C-4.2. Please note: Anesthesia reports must include start and stop times as fees are determined by the length of time of this service.

Form EC-4 AMR can only be accepted by the Board through electronic submission.

Form EC-4 AMR is available in a new Adobe format which includes features to assist in completing and electronically submitting the form. In addition, the Board is prepared to work with providers, practice management software vendors and third parties to accept EC-4 AMR forms through electronic batch submission, which offers the possibility of insurance carriers also receiving the report electronically. Additional information on Form EC-4 AMR and electronic submission options, can be found at: Please be sure to check this page periodically for additional updates.

General questions regarding the use of EC-4 AMR should be referred to the Bureau of Health Management at (800)781-2362. For technical questions or assistance, please call the Board's helpdesk at (866) 868-9746.


Zachary S. Weiss