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01. Edit your c 4 amr online
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How to use or fill out the ancillary report with our platform
- Click ‘Get Form’ to open the ancillary report in the editor.
- Begin by filling out Section A, which requires the patient's information. Enter the patient's name, social security number, mailing address, home phone number, date of birth, date of injury or onset of illness, WCB case number (if known), carrier case number, and patient account number.
- Proceed to Section B for the doctor's information. Input your name, WCB authorization number, federal tax ID number, office address, billing group name, and contact numbers.
- In Section C, provide billing information including the employer's insurance carrier details and diagnosis codes. Ensure you enter dates of service and any relevant CPT/HCPCS codes accurately.
- Review all sections for completeness before submitting. Attach any necessary reports for services provided as required.
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