Form SI-1b Statement of Sickness

United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0039

Statement of Sickness
/nstr~ctions:This form is to be executed by (1) a doctor trained in medical, surgical, dental orpsychologicaldiagnosis

of
the infirmity described, (2) a certified nurse/midwife in cases of pregnancy or childbirth, (3) a supervisory official of a hospital or similar institution, (4) a chiropractor, (5) a Physician Assistant Certified, or (6) a nurse practitioner. This form should
be completed and returned to the patient immediately for prompt mailing; otherwise hdshe may lose benefits. Supplementary
medical information may be attached or furnished directly to the Railroad Retirement Board (RRB) at the address shown below.
If such information is furnished, please include the patient's social security number and name on the report. Please complete
section 2 on the next page if patient is incapable of signing forms.

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1. Patient's Name (First, Middle, and Last)

2. Patient's Social Security Number

CI

3. Have you examined or treated the patient for his or her injury or illness?
Yes [] No - Go to ltem 9
a. Date patient became sick or injured
b. List all dates of examination and treatment for this infirmity
c. Probable date of next examination
1

4. Diagnosis and concurrent conditions

5. Does the patient's condition require surgery?
a. Date on which surgery was or will be performed

Yes

a

No -Go to ltem 6

b. Surgical procedure that was or will be performed
I

6. Does the patient's condition require hospitalization?

CI
CI

To

Yes - Give the period of hospital confinement: From
No

7. If patient is not working because of maternity or childbirth, give:
a. Date patient became unable to work,

b. Estimated or actual date of delivery,

8. Give the date you believe the patient became or will become able to resume work in his or her occupation.
(If indefinite or unknown, please give an estimated date.))

9. 1 certify that the information I am giving is true, complete, and correct. I understand that criminal andcivil penalties may be imposed
on me for false or fraudulent statements or for withholding information to cause or prevent payment of benefits by the RRB.
Please print or type:
-.
Name of Doctor

Signature of Doctor

DegreelTitle

Address

Ofice Telephone Number (Include Area Code)

Date

(

)

Tax Identification Number
I

PAPERWORK REDUCTION ACT NOTICE TO DOCTOR
Medical evidence is needed to support the payment of claims for sickness benefits under the Railroad Unemployment InsuranceAct (RUIA). The RRB is
authorized to collect this information under section 12(i) of the RUIA. You are not required to furnish this information. If you do not, however, no benefits
can be paid to your patient. We estimate this form and the form on the next page take an average of 8 and 6 minutes to complete, respectively.
The estimates include the time for reviewing the instructions, getting the needed data, and reviewing the completed forms. Federal agencies may not con
duct or sponsor, and respondents are not required to respond to, a collection of information unless it displays a valid OMB number. If you wish, send corn
ments regarding the accuracy of our estimate or any other aspect of this form, including suggestions for reducing completion time, to the Chief of
Information Resources Management, Railroad Retirement Board, 844 N Rush Street, Chicago, Illinois, 60611-2092. Send completed forms to:

U.S. RAILROAD RETIREMENT BOARD
OFFICE OF PROGRAMS-OPERATIONS
POST OFFICE BOX 10695
CHICAGO, ILLINOIS 60610-0695
Doctor: See Next Page

FORM SI-I b (02-01)

United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0034

Statement Of Authoritv To Act For Em~lovee
It is not necessary to complete this form for an employee who can sign papers or can
sign by mark and undersfands transactions relating to his or her sickness benefits.

Instructions
1. Complete Section 1 and have the employee's medical doctor complete Section 2. If you are not related to the

employee by blood or marriage, state your relationship and why no relative is acting for him or her. For example,
a n employee's union representative might explain: "I am his union chairman. He has no immediate family."

2. Complete this statement by following the instructions in the UB-11 booklet under "Instructions for Completing
Forms, Statement of Authority to Act for Employee (SI-lo)." Signing this statement gives you the authority to
sign any claim forms on behalf of the employee. When signing claim forms use your full name, and beneath your
signature, write "On behalf of' and the employee's full name.
3. Return this form with the next application or claim form you file with the RRB.
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Statement of Individual Acting for Employee
I t i s my belief t h a t
(Employee's Name)

(Social Security Number)

whose address is
(Employee's
Address)
.
- is a t this time incapable of signing forms i n connection with obtaining sickness benefits under the Railroad
Unemployment Insurance Act; of transacting the necessary business relative to his or her application and claims
for such benefits; and of applying the proceeds of any sickness benefit payments.

I believe the employee to be incapable because

(Briefly describe employee's condition)
My relationship t o t h e employee is

I affirm that, in the transaction of business relating to the application and claims of this employee, including the
use of any benefit payments, I will act on behalf of and in the best interest of the employee. I will promptly notify the RRB a t such time a s this employee's condition changes so t h a t I need no longer act for him or her. I understand that criminal and civil penalties may be imposed on me for providing false, incomplete, or fraudulent statements, or for withholding information to cause the payment of benefits. I certify that, to the best of my knowledge,
the information I have provided is true, complete, and correct.
Name (please print)

Signature

Street Address (please print)

City

Phone Number
(

)

State ZIP Code Date

Statement of Employee's Doctor
I have examined the employee named above and find t h a t hetshe is incapable of signing forms and transacting business relative to histher claims for sickness benefits under the Railroad Unemployment Insurance Act.
Name of Doctor (please print)
Office Street Address (please print)
Tax Identification Number

FORM SI-10 (02-01)

Signature of Doctor
City

State ZIP Code Date