The C-4AMR (Ancillary Medical Report) is a workers' compensation form required in New York State. It is filed by board-authorized health care providers who supply non-treatment ancillary services such as x-rays, anesthesia, pathology, lab testing, and diagnostic procedures in cases where the claimant holds a workers' compensation claim. The reporting provider must not be the attending physician on the case.
Providers complete the C-4AMR to document each ancillary procedure, link it to the correct ICD diagnosis code, and certify that the procedures were directly supervised or performed by the billing provider. Accurate and timely completion is critical for authorizing fee payment by the insurance carrier and for maintaining the provider's authorization with the Board.
Once completed, the report is submitted to the Workers' Compensation Board and the claimant's insurance carrier. When the claimant has legal representation, a copy must also go to the attorney. Late or inaccurate submission can delay processing and result in withheld payments. The related Workers' Compensation C-4 Form is used by attending physicians, while this form covers ancillary providers. See also the Workers' Compensation Injury Report for initial injury documentation.
| Question | Answer |
|---|---|
| Form Name | C 4Amr Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Form Topic | Employment |
| Compatible with | Adobe Acrobat Reader, Foxit Reader, Google Docs |