SI-7 (06-09) Supplemental Doctor's Statement

Fonn Approved
OMB No. 3220-0039

UNITED STATES OF AMERICA

RAILROAD RETIREMENT BOARD
OFFICE OF PROGRAMS
POST OFFICE Box 10695

CmcAGo,IL 60610-0695

In reply refer to
SSNo.:

Instructions to Claimant
You must have your doctor complete the next page of this form if you wish to claim benefits
for days after
. If you have recently provided medical evidence beyond this date, please
disregard this notice. 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 aspect of this form, including suggestions for reducing
completion time, to Chief of Information Resources Management, Railroad Retirement Board, 844
N. Rush Street, Chicago, Illinois 60611-2092.
(Continued On Next Page)
SI-7 (06-09)

United States of America
Railroad Retirement Board

Fonn Approved
OMB No. 3220-0039

Social Security Number

SUPPLEMENTAL DOCTOR1S
STATEMENT

Patienrs Name

INSTRUCTIOI\lS 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 injury?
UYes
UNo
If "Yes," give the date you last examined or treated the patient:

2. Please give:
A. Diagnosis:
B. Current objective finding:
C. Complications (show any factors retarding recovery):
D. Current response to treatment:

3. Did the patient require surgery?

UYes

D No - Go to Item 4

If "Yes" - A. Indicate the type of surgery:
B. Date of most recent surgery:
4. If maternity, give estimated or actual date of delivery:

5. Do you believe the patient is now able to work without restriction in his/her last occupation?

A.

DYes - Give the date the patient became able to work:

B. D No - Give an estimated return-to-work date and explain how the medical evidence shows the
patient is still disabled.
Estimated return-to-work date (if indefinite, give estimated date):
Exolanation:

6. Has the patient reached maximum medical recovery?

UYes

U No - Go to Item 7

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

DYes

DNo

7. 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.

Signature of Doctor

Degree/Title
Name of Doctor (Print or Type)

Date

Address (Print or Type)

Office Telephone Number (Include area code)

(
)

City, State, ZIP Code

National Provider Identifier

I I

I I I I I I I

81-7 (06-09)