Request for Medical Assessment

Form Approved
OMB No. 3220-0038

UNITED STATES OF AMERICA

RAILROAD RETIREMENT BOARD
BIS - INFORMATION RESOURCES MANAGEMENT
844 NORTH RUSH STREET

CURRENT

CHICAGO, IL 60611-2092
WWW.RRB.GOV

OFFICE HOURS: 9:00 AM TO 3:30 PM
MONDAY THROUGH FRIDAY

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

In reply refer to
RR Employee:
RRB Claim No.:

The patient named above has filed for disability benefits with the Railroad Retirement Board
(RRB).
The RRB must make an independent determination of disability based on medical evidence of
the patient's impairment. Because we feel that you, as a treating physician, are the best source
for this information, we request that you submit a copy of your office records on the claimant's
treatment for at least the last 12 months. Also, include copies of all available laboratory,
hospital, and consultative reports.
In addition to the copies of your office records, complete the enclosed Form G-250, Medical
Assessment.
Providing this information is essential for the RRB to determine your patient's
entitlement to benefits.
Your cooperation in this matter is greatly appreciated and will assist us in evaluating this claim
for disability benefits in a timely manner.
Return the enclosed form along with this cover letter to the address shown above within 20 days
from the date you receive this letter.
This is not an authorization to conduct a new examination.

RRB Form RL-250 (09-05)

UNITED STATES RAILROAD RETIREMENT BOARD - 2

Since claimants are responsible for presenting medical evidence on their own behalf from the
personal physicians, any fee that may result from completion of this report is a personal
matter between the claimant and you.
Authorization to release medical information is enclosed.
Sincerely,

Enclosures
Form G-250
Form G-197

PAPERWORK REDUCTION ACT AND PRIVACY ACT NOTICES
The Railroad Retirement Board’s authority for requesting this information is Section 7 (b)(6) of
the Railroad Retirement Act. While you are not required to respond, your cooperation is needed
to provide information necessary to complete processing for the claimant named and to
determine the claimant’s entitlement to disability benefits under the Railroad Retirement Act.
We estimate that this form takes an average of 10 minutes to complete, including the time for
reviewing the instructions, getting the needed data, and reviewing the completed information.
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 North Rush Street, Chicago, Illinois 60611-2092.

RRB Form RL-250 (09-05)