Use this form to report ancillary medical services such as x-ray, anesthesia, pathology or diagnostic services by other than the attending provider. A medical provider who is only giving clearance for surgery may also use this form. THIS FORM SHOULD NOT BE USED TO REPORT TREATMENT PROVIDED. Ancillary Medical Report C-4 AMR Please answer all questions completely, attaching the report for the services provided, and submit promptly to the Board, 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. Failure to do so may delay the payment of necessary services, prevent the timely payment of wage loss benefits to the injured worker, create the necessity for testimony, and jeopardize your Board authorization. You may also fill out this form online at www.wcb.ny.gov. A. Patient's Information 1. Name: 3. Mailing address: Last First MI 2. Soc. Sec. #: City State - Zip Code Number and Street 4. Home phone #: (_____)_______________ 5. Date of Birth: ______/______/______ 6. Date of injury/onset of illness: ______/______/______ 7. WCB Case # (if known): 8. Carrier Case #: 9. Patient's Account #: 2. WCB Authorization #: The Tax ID # is the (check one ): City State B. Doctor's Information 1. Your name: 3. WCB Rating Code: 5. Office address: 6. Billing group or practice name: 7. Billing address: Number and Street City State Zip Code Last First MI 4. Federal Tax ID #: Number and Street SSN Zip Code EIN 8. Office phone #: (______)_____________ 9. Billing phone #: (______)______________ 10. Provider's NPI #: 11. Referring Doctor: Last First MI C. Billing Information 1. Employer's insurance carrier: 3. Insurance carrier's address: 4. Diagnosis or nature of disease or injury: Enter ICD10 Code: ICD10 Descriptor: (1) (2) (3) Relate ICD10 codes in (1), (2) or (3) to Diagnosis Code column by line. Dates of Service From MM To DD YY MM DD YY Place of Service Leave Blank 2. Carrier Code #: W Number and Street City State Zip Code Procedures, Services or Supplies CPT/HCPCS MODIFIER Use WCB Codes Diagnosis Code $ Charges Days/ Units COB Zip code where service was rendered Check here if services were provided by a WCB preferred provider organization (PPO). Total Charge Amount Paid (Carrier Use Only) Balance Due (Carrier Use Only) $ $ $ Board Authorized Health Care Provider - Check one: I provided the services listed above. I actively supervised the health-care provider named below who provided these services. Provider's name___________________________________________________ Specialty______________________________________ Board Authorized Health Care Provider signature: / / Name C-4AMR (10-15) Signature Specialty American LegalNet, Inc. www.FormsWorkFlow.com Date www.wcb.ny.gov MEDICAL REPORTING 1. IMPORTANT - TO THE SERVICE PROVIDER This form is to be used to file reports for ancillary medical services such as x-ray, anesthesia, pathology or diagnostic services by other than the attending provider in workers' compensation, volunteer firefighters' or volunteer ambulance workers' benefit cases. A medical provider who is only giving clearance for surgery may also use this form. 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 claimant is not represented, a copy must be sent to the claimant. This form is not used to report treatment. To report treatment or to report an ancillary service where treatment is also provided, use forms: C-4, 48 HOUR REPORT, complete in all details, within 48 hours after you first render treatment. C-4.2 to report continued treatment. C-4.3 to report permanent impairment. Ophthalmologists use Form C-5, Occupational/Physical Therapists use Form OT/PT-4 and Psychologists use Form PS-4 for filing reports. 2. 3. Please ask your patient for his/her WCB Case Number and the Insurance Carrier's Case Number, if they are known to him/her, and show these numbers on your reports. In addition, ask your patient if he/she has retained a representative. If so, ask for the name and address of the representative. You are required to send copies of all reports to the patient's representative, if any. This form must be signed by the doctor providing or supervising the ancillary service and must contain his/her authorization certificate number, code letters and NPI number. If the patient is hospitalized, it may be signed by a licensed doctor to whom the treatment of the case has been assigned as a member of the attending staff of the hospital. AUTHORIZATION FOR SPECIAL SERVICES - Form C-4 AUTH should be used to request any special medical service over $1000 or for those services requiring preauthorization pursuant to the Medical Treatment Guidelines for the back, neck, knee and shoulder. 4. AUTHORIZATION FOR SPECIAL SERVICES IS NOT REQUIRED IN AN EMERGENCY 5. 6. LIMITATION OF PODIATRY TREATMENT - Podiatry treatment is limited as defined in Section 7001 of the Education Law and Section 13-k(2) of the Workers' Compensation Law. LIMITATION OF CHIROPRACTIC TREATMENT - Chiropractic treatment is limited as defined in Section 6551 of the Education Law and the Chair's Rules Relative to Chiropractic Practice Under Section 13-l of the Workers' Compensation Law. A CHIROPRACTOR OR PODIATRIST FILING THIS REPORT CERTIFIES THAT THE INJURY DESCRIBED CONSISTS SOLELY OF A CONDITION(S) WHICH MAY LAWFULLY BE TREATED AS DEFINED IN THE EDUCATION LAW AND, WHERE IT DOES NOT, HAS ADVISED THE INJURED PERSON TO CONSULT A PHYSICIAN OF HIS/HER CHOICE. 7. HIPAA NOTICE - In order to adjudicate a workers' compensation claim, WCL13-a(4)(a) and 12 NYCRR 325-1.3 require health care providers to regularly file medical reports of treatment with the Board and the carrier or employer. Pursuant to 45 CFR 164.512 these legally required medical reports are exempt from HIPAA's restrictions on disclosure of health information. ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD PRESENTS, CAUSES TO BE PRESENTED, OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, OR SELF-INSURER, ANY INFORMATION CONTAINING ANY FALSE MATERIAL STATEMENT OR CONCEALS ANY MATERIAL FACT SHALL BE GUILTY OF A CRIME AND SUBJECT TO SUBSTANTIAL FINES AND IMPRISONMENT. BILLING INFORMATION Complete all billing information contained on this form. Use continuation Form C-4.1, if