RL-11D (Proposed) Discloure of Medical Records from a State Agency

Proposed

UNITED STATES OF AMERICA

Form Approved
OMB No. 3220-0038

RAILROAD RETIREMENT BOARD
OFFICE/P
NAME
OFFICE OF PROGRAMS
OLICY & SYSTEMS
ADDRESS
RUSH STREET
844 NORTH
CITY,, STATE,
ZIP
CHICAGO
IL 60611-1275
WWW.RRB.GOV
OFFICE HOURS: M-T-TH-F 9:00 AM TO 3:30 PM
WEDS. 9:00 AM TO 12:00 PM - CLOSED FEDERAL HOLIDAYS

TOLL-FREE NUMBER: 1-877-772-5772

,
In reply refer to

REQUEST FOR WORKERS COMPENSATION/PUBLIC DISABILITY BENEFIT
MEDICAL EVIDENCE
The person identified on the next page has applied for or is receiving disability benefits under the
Railroad Retirement Act. To assist us in determining whether such benefits are payable, please
furnish copies of any records describing this person's disability as well as any medical records you
have including:
 transcripts of in-hospital and out-patient treatment;
 transcripts of examinations for compensation or pension; and
 transcripts of any vocational training.
Send the records as soon as possible to the Railroad Retirement Board (RRB) address shown
above. Be sure to include the person’s RRB claim number in your reply. If, for any reason, you are
unable to furnish medical records, please notify this office immediately.
Since the RRB is an agency of the United States Government, the information should generally be
furnished without charge. It is needed to establish entitlement to benefits under a federal law.
Authorization to release medical information to the RRB is enclosed. Your cooperation in
furnishing the required information as soon as possible will be appreciated. Patient identifying
information follows.

XX-XX

RRB Form RL-11D (12-11)

UNITED STATES RAILROAD RETIREMENT BOARD - 2

IDENTIFYING INFORMATION
Name and Address of Applicant/Annuitant:

Social Security No.:
Date of Birth:
Worker’s Compensation or Disability Benefit Beginning Date:
Employing Agency or Company:
Claim No. at Employing Agency or Company:
Period of Disability:
Nature of Disability:
Other Identifying Information:
Sincerely,

Enclosure
Form G-197

PAPERWORK REDUCTION ACT NOTICE
We estimate this form takes an average of 10 minutes per response to complete, including 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, IL 60611-1275.
Associate Chief Information Officer for Policy and Compliance

XX-XX

RRB Form RL-11D (12-11)