SI-1b (proposed) Statement of Sickness

United States of America
Railroad Retirement Board

FormApproved
OM0

No.3220-0039

Statement of Sickness
/nSf~l.l~fi~nS:
This form is to be executed by (I)a doctor trained in medical, surgical, dental or psychologicaldiagnosis of
the infirmity described, (2) a certified nurselmidwife in cases of pregnancy or childbirth, (3) a supervisory official of a hospital or similar institution, (4) a chiropractor, (5) a Physician Assistant Certifed, or (6) a nurse practitioner. This form should
be completed and returned to the patient immediately for prompt mailing; otherwise helshe 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.

-

2. Patient's Social Security Number

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

3. Have you examined or treated the patient for his or her injury or illness? [7 Yes [7 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
I

4. Diagnosis and concurrent conditions

5. Does the patient's condition require surgery?

Yes

n

No -Go to ltem 6

a. Date on which surgery was or will be performed

b. Surgical procedure that was or will be performed

6. Does the patient's condition require hospitalization?

n

Yes - Give the period of hospital confinement: From

To

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 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.

Please print or type:
Name of Doctor

Signature of Doctor

Address

Office Telephone Number (Include Area Code)

(

Date

1

National Provider Identifier

PAPERWORK REDUCTION ACT NOTICE TO DOCTOR

Medical evidence is needed to support the payment of claims for sickness benefits under the Railroad Unemployment Insurance Act (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 cow
duct or sponsor, and respondentsare 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 (xx-xx)