SI-7 Supplemental Doctor's Statement

Form Approved
OMB NO.3220-0039

In reply refer to
SS No.:

Instructions to Claimant
You must have your doctor complete the next page of this form if you wish to claim benefits
for days after
. The Railroad Retirement Board's authority for requesting this statement is
45 U.S.C. 362(i) and 20 CFR 335.3. Be sure to complete and return promptly any sickness benefit
claim forms you receive. Do not give claims to your doctor.

IMPORTANT NOTICE
Paperwork Reduction Act Notice to Doctor
Additional medical evidence is needed to support further claims for sickness benefits under the
Railroad Unemployment Insurance Act (RUIA). This information is to be supplied without expense
to the Railroad Retirement Board (RRB). Please complete the items on the next page. 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 will be paid to your patient.
We estimate this form takes an average of 8 minutes to complete, including the time for reviewing
the instructions, getting the needed data, and reviewing the completed form. Federal agencies
may not conduct 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 comments regarding the
accuracy of our estimate or any other aspects of this form, including suggestions for reducing
completion time, to Chief of Information Management, Railroad Retirement Board, 844 N. Rush
Street, Chicago, Illinois 6061 1-2092.
(Continued On Next Page)

United States of America
Railroad Retirement Board

Form Approved
OMB NO. 3220-0039

Social Security Number

SUPPLEMENTAL DOCTOR'S
STATEMENT
I

1

INSTRUCTIONS TO DOCTOR: Please complete all items and return this form in the enclosed
envelope to the Railroad Retirement Board (RRB) immediately. No additional sickness benefits can be
paid to this patient until this supplemental medical form is completed and returned. This information is to
be supplied without expense to the RRB. Also read the "Important Notice" on the previous page of this
form.
1. Have you examined or treated the patient for illness or ipjury?
U Yes l-j IVo
lf " ~ e s . "give the date you last examined or treated the patient:

1 2.

1

I
1
1

s
I

Please give:
A. Diagnosis:

I

B. Current objective finding:
C. Complications (show any factors retarding recovery):
D. Current response to treatment:
3.

Did the patient require surgery?

U Yes

I

U IVo - Go to Item 4

If "Yes" - A. Indicate the type of surgery:
B. Date of most recent surgery:
4.

I 5.

6.

If maternity, give estimated or actual date of delivery:
DOyou believe the patient is now able to work without restriction in hislher last occupation?
A.
Yes - Give the date the patient became able to work:
B.
No - Give an estimated return-to-work date and explain
patient is still disabled.
Estimated return-to-work date (if indefinite, give estimated date):
Explanation:

Has the patient reached maximum medical recovery?

.

U Yes

U No - Go to ltem 7

If "Yes" - A. Give the date the patient reached maximum recovery:
B. Is the patient able to do some kind of work?
7.

Yes

No

1 certify that the information I am giving is true, complete, and correct. I understand that criminal and
civil 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.
DegreelTitle
Signature of Doctor

1

1

I

Name of Doctor (Print or Type)

Date

Address (Print or Type)

Office Telephone Number (Include area code)
(
1
Tax Identification Number

City, State, ZIP Code