G-478 Statement Regarding Patient's Capability to Manage Payme

United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0052

RRB Claim Ilumber:
Employee's ss Number:

Statement Regarding
Patient's Capability
to Manage Benefits

Employee's Name:
Beneficiary's SS Number:
Beneficiary's Name:
I

PhysicianlMedical Officer
Name, Address, and Telephone Number

RRB Information
Office Number:
Date Released:
U. S. RAILROAD RETIREMENT BOARD

;elephone

Number:

Paperwork Reduction and Privacy Act Notice

a

This report is authorized by Section 7 of the Railroad Retirement Act, as amended (45 U.S.C. 231f . While ou are not re uired to
respond, your cooperation will help us decide whether any railroad retirement benefits that may be ue shoul be paid direct y to the
patlent or to someone else on the patient's behalf. Although we cannot reimburse ou for your semces, your cooperation In completing
and returning t h i ~
statement will be appreciated. Please answer all items as compLtely as poss~ble. If you need more space, you may
use ltem 8 for thls purpose. For your convenience we have enclosed an envelope requiring no postage.

J

9

We estimate this form takes an average of 6 minutes per response to complete, includin the time for reviewing the instructions, getting
the needed data, and review$ the cpmpleted form. Federal agencies may not conductor sponsor. and responde?ts are not required
to respond to, a collect~onof in?ormatlon unless it d s lays a valid OMB number. If you w~sh,send comments regarding the accuracy of
our estimate or any other aspect of this form, incluin su estions for reducin completion time to Chief of lnformation Resources
Management. Ra~lroadRetirement Board, 844 N. Rush
8iicago, Illinois 6061 ?-2092.

&..

Patient Name and Address
I.
I

I

Physician's Statement
2. Provide the date of your most recent
examination.
Day

Month

Year

3. In your opinion, is the
patient able to manage
benefit payments in
the patient's best
interest?

Yes -- Go to ltem 9
No -- Go to Item 4

NOTE: The ability to manage benefit payments in the patient's best interest is the ability to understand and
act on the ordinary affairs of life, such as providing for one's own adequate food, housing, cloth~n etc., and
the ability, in spite of hysical impairment, to manage funds. The physical ability to endorse chec s is not
sufficient to indicate he ability to manage benefit payments.

Q

f

4.

Do you expect the patient to recover sufficiently
to handle benefit payments in the patient's best
interest?

Yes
Expected date of recovery
No
Undetermined

Page 2

5. Describe the medical condition(s) which impair(s)
the patient's ability to manage benefit payments.
If you need additional space, continue in ltem 8.

6. Has anyone assumed responsibility for the
patient's welfare?
7 . Name

City and State
Area Code

Yes -- Go to Item 7

No -- Go to Item 9

Number and Street, P.O. Box, or Rural Route

ZIP Code
Telephone Number

Relationship to patient:

Spouse
Relative
Specify relationship
Legal Guardian
Other
Specify

8. Remarks

9. Certification

I certify that the information I have given is true, complete, and correct. I understand that criminal or civil
penalt~esmay be imposed on me for false or fraudulent statements.

Physician's Signature
Physician's Name (Please Print)

Date