Form SI-7

UNITED STATES OF AMERICA

RAILROAD RETIREMENT BOARD
OFFICE OF PROGRAMS
POST OFFICE BOX 10695

CHICAGO, IL 60610-0695

Form Approved
OMB No. 3220-0039

PROPOSED

Instructions to Claimant
You must have your health care provider 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 health care provider.

IMPORTANT NOTICE
Paperwork Reduction Act Notice to Health Care Provider
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 Associate Chief Information Officer for Policy and Compliance, Railroad
Retirement Board, 844 N. Rush Street, Chicago, Illinois 60611-1275.
(Continued On Next Page)
SI-7 (XX-XX)

United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0039
Social Security Number

SUPPLEMENTAL
HEALTH CARE PROVIDER'S
STATEMENT

Patient's Name

INSTRUCTIONS TO HEALTH CARE PROVIDER: 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?
Yes
No
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?

Yes

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.

Yes – Give the date the patient became able to work:

B.

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):
Explanation:

6.

Has the patient reached maximum medical recovery?

Yes

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?
Yes
No
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 Health Care Provider
Degree/Title
Name of Health Care Provider (Print or Type)

Date

Address (Print or Type)

Office Telephone Number (Include area code)
(
)

City, State, ZIP Code

National Provider Identifier

SI-7 (XX-XX)