Form SI-8

PROPOSED
FORM APPROVED OMB NO. 3220-0039

UNITED STATES OF AMERICA

RAILROAD RETIREMENT BOARD
OFFICE OF PROGRAMS - OPERATIONS
POST OFFICE BOX 10695
CHICAGO, ILLINOIS 60610-0695
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

,

VERIFICATION OF MEDICAL INFORMATION
The purpose of this notice is to verify the accuracy of the enclosed photocopy of a medical report received from
your office. Please examine the report to check for errors or falsifications by the patient. Reply ONLY if:
1. the subject of the report is not your patient;
2. your office did not complete the report; or
3. the report was not accurate when made.
If the report is incorrect, please show corrections or further information below and sign and mail this form to the
address shown above.
DO NOT REPLY IF THE REPORT IS CORRECT.
Thank you for your cooperation.
U. S. Railroad Retirement Board
READ IMPORTANT NOTICES ON THE NEXT PAGE
PATIENT:

SS NO.:

Do not complete or return this form if the enclosed report is correct. If the report is erroneous, please check all
applicable boxes and provide any relevant information.
The subject is not my patient.

My office did not complete the report.

The subject was not my patient at the time the
medical report was completed.

The report was not accurate when made.

REMARKS:

_______________________________

______________________________

NAME OF PROVIDER

SIGNATURE OF PROVIDER

________________
DEGREE/TITLE

_______________________________

_(____)________________________

________________

ADDRESS

TELEPHONE NUMBER

DATE

_______________________________
_

__________________________________
NATIONAL PROVIDER IDENTIFIER

SI-8 (XX-XX)

Paperwork Reduction Act Notice to Health Care Provider
If information is furnished, it is to be furnished without expense to the Railroad Retirement Board (RRB). If
applicable, please complete the items on the reverse side. The RRB is authorized to collect this information under
section 12(i) of the Railroad Unemployment Insurance Act. You are not required under law to provide any of the
information requested on the reverse side of this form. However, if for any reason you do not provide relevant
information, benefits may be improperly paid to this patient or denied by the RRB.

We estimate this form takes an average of 5 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 Associate Chief Information Officer for Policy & Compliance, Railroad
Retirement Board, 844 Rush St., Chicago, Illinois 60611-1275.

SI-8 (XX-XX)