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

PROPOSED

United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0052

RRB Claim Number:
Employee’s SS Number:

Statement Regarding
Patient’s Capability
to Manage Benefits

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

Print the name, address, and telephone number of
the Physician/Medical Officer in the space below.

Name:

RRB Information
Office Number:
Date Released:

Address:

U. S. RAILROAD RETIREMENT BOARD
Telephone Number:
Paperwork Reduction Act and Privacy Act Notices
This report is authorized by Section 7 of the Railroad Retirement Act, as amended (45 U.S.C. 231f). While you are not required to
respond, your cooperation will help us decide whether any railroad retirement benefits that may be due should be paid directly to the
patient or to someone else on the patient’s behalf. Although we cannot reimburse you for your services, your cooperation in completing
and returning this statement will be appreciated. Please answer all items as completely as possible. If you need more space, you may
use Item 8 for this purpose. For your convenience we have enclosed an envelope requiring no postage.
We estimate this form takes an average of 6 minutes per response 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 Associate Chief Information Officer
for Policy & Compliance, Railroad Retirement Board, 844 N. Rush St., Chicago, Illinois 60611-1275.

Patient Name and Address - Please Print
1.
Physician’s Statement
2. Provide the date of your most recent
examination.
Month

Day

Year

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

Yes -- Go of
to the
Itempatient.
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, clothing, etc., and
the ability, in spite of physical impairment, to manage funds. The physical ability to endorse checks is not
sufficient to indicate the ability to manage benefit payments.
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

G-478 (XX-XX)

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 Item 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 - Must Be Completed
I certify that the information I have given is true, complete, and correct. I understand that criminal or civil
penalties may be imposed on me for false or fraudulent statements.

Physician's/Medical Officer’s Signature

Date

Physician's/Medical Officer’s Name and Title
(Please Print)

G-478 (XX-XX)