Ancillary report 2025

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61 votes

The C-4 AMR is an Ancillary Medical Report form used to report ancillary medical services such as x-ray, anesthesia, and diagnostic services provided by non-attending providers in workers' compensation cases. It outlines the necessary patient and provider information, billing details, and submission requirements to ensure timely processing of claims. The form emphasizes that it should not be used for treatment reporting and includes instructions for proper completion and submission to relevant parties.

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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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Versions	Form popularity	Fillable & printable
2015	4.8 Satisfied (61 Votes)
2011	4 Satisfied (52 Votes)

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What is ancillary report in medical terms?

The term ancillary is used in medicine to refer to diagnostic or therapeutic procedures which are supplementary to the main tests or treatments. By extension it is also employed for secondary clinical/radiological signs that support a diagnosis.

What is meant by ancillary?

: having a subordinate, subsidiary, or secondary nature. ancillary functions. an ancillary agreement. 2. : serving as a supplement or addition.

What is an example of ancillary data?

Lab testing and ECG services are two of the most common ancillary services for this reason.

What is the meaning of ancillary document?

Ancillary documents are papers, forms, and other information that are related to a main document. 3 min read updated on January 01, 2024. Ancillary documents are papers, forms, and other information that are related to a main document. They are often used as a method to verify and support a main document.

What is the meaning of ancillary information?

Common examples are cover art images for media files or streams, or digital data added to radio or television broadcasts.

ancillary medical report

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What are some examples of ancillary?

Examples of ancillary services include: Ambulance services. Ambulatory surgery center (ASC) services. Audiology services. Behavioral health services (inpatient and outpatient) Cardiac monitoring. Dialysis services. Durable medical equipment (DME) Hearing services.

What is an example of ancillary information?

Ancillary services are medical services or supplies that are not provided by acute care hospitals, doctors or health care professionals. Examples of ancillary services include: Ambulance services. Ambulatory surgery center (ASC) services.