Form SI-1b (06-09) SI-1b (06-09) Statement of Sickness

United States of America
Railroad Retirement Board

Form Approved
OMS No. 3220-0039

Statement of Sickness

Instructions:

This form is to be executed by (1) a doctor trained in medical, surgical, dental or psychological diagnosis 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 he/she 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 reverse side if patient is incapable of signing forms.

The RRB is not liable for any charge in connection with completing this form.

2. Patient's Social Security Number

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

3. Have you examined or treated the patient for his or her injury or illness? 0 Yes 0 No - Go to Item 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

4.

Diagnosis and concurrent conditions

5. Does the patient's condition require surgery?

0

Yes

0

No - Go to Item 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?

o
o

7.

Yes- Enter the period of hospital confinement: From _ _ _ _ _ _ _ _ _ _ _ To _ _ _ _ _ _ _ _ _ __
No

If patient is not working because of maternity or childbirth, complete 7a and 7b.
b. Estimated or actual date of delivery ~
a. Date patient became unable to work ~

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. I 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

Degree/Title

Address

Office Telephone Number (Indude Area Code)

Date

(

)

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 back of this 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
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 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-1b (06-09)

United States of America
Railroad Retirement Board

Form approved
OMS No. 3220·0034

Statement Of Authority To Act For Employee

It is not necessary to complete this form for an employee who can sign papers or can
sign by mark and understands 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 employ­
ee by blood or marriage, state your relationship and explain why no relative is acting for the employee. For exam­
ple, an 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-II 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.

Section 1

Statement of Individual Acting for Employee

It is my belief that
(Employee's Name)

whose address is

(Employee's Address)

is at this time incapable of signing forms in 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 to the 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 at such time as this employee's condition changes so that 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; using
the benefits received on something other than the claimant; 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)

Phone Number

Signature

(

Street Address (please print)

Section 2

City

)

State ZIP Code Date

Statement of Employee1s Doctor

I have examined the employee named above and find that he/she is incapable of signing forms and transacting
business relative to hislher claims for sickness benefits under the Railroad Unemployment Insurance Act.
Name of Doctor (please print)
Office Street Address (please print)
National Provider Identifier

51·10 (06-09)

Signature of Doctor
City

State ZIP Code Date