3220-0038

OMB No. 3220-0038

Justification

Medical Reports

RRB Forms G-3EMP, G-197, G-250, G-250A, G-260, RL-11B, RL-11D and RL-250

1. Circumstances of information collection - Under sections 2(a)(1)(iv) and 2(a)(1)(v) of the Railroad Retirement Act (RRA), annuities are payable to qualified railroad employees whose physical or mental condition makes them (1) unable to work in their regular occupation (occupational disability) or (2) unable to work at all (permanent total disability). The requirements for establishing disability and proof of continuing disability under the RRA are prescribed in 20 CFR 220.

Under sections 2(c) and 2(d) of the RRA, annuities are also payable to qualified spouses and survivors of the employee. Under sections 2(c)(1)(ii)(C) and 2(d)(1)(ii), annuities are payable to spouses and widow(ers), respectively, who have a qualifying child who became disabled before age 22. Under section 2(d)(1)(iii)(C) annuities are also payable to surviving children on the basis of disability if the child’s disability began before age 22 and, under section 2(d)(1)(i)(B) annuities are payable to widow(er)s on the basis of disability. To meet the disability standard, the RRA provides that individuals must have a permanent physical or mental condition that makes them unable to engage in any regular employment.

Under section 2(d)(1)(v) of the RRA, annuities are also payable to remarried widow(er)s and surviving divorced spouses on the basis of, among other things, disability or having a qualifying disabled child in care. However, the disability standard applicable in these cases is that found in the Social Security (SS) Act. That is, individuals must be unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment. The Railroad Retirement Board (RRB) also determines entitlement to a Period of Disability and entitlement to early Medicare based on disability for qualified claimants in accordance with section 216 of the SS Act.

When making disability determinations, the RRB needs evidence from acceptable medical sources (see 20 CFR 220.46 and 404.1513).

2. Purposes of collecting/consequences of not collecting the information - To enable the RRB to determine the eligibility of an applicant or annuitant for disability benefits under the RRA, the RRB requests supportive medical evidence from railroad employers, personal physicians, private hospitals, and state agencies. Obtaining needed medical evidence is currently accomplished by the use of request Forms G-3EMP, G-197, G-250, G‑250A, G-260, RL-11B, RL-11D, and RL-250.

Information about the medical reports forms follow.

Form G-3EMP, Report of Medical Condition by Employer, obtains medical information, relevant to an employee's inability to work, from the medical officer or official of an applicant's or annuitant's railroad employer.

Form G-3EMP is initiated by an RRB field office and is transmitted by Form Letter RL-11, which asks the employer to complete Form G-3EMP and provide information on the disability claimant. The RL-11 includes instructions for furnishing the requested information and identifying employee information. The employee's consent for the disclosure of the medical records is contained on Form G-197, Authorization to Disclose Information to the Railroad Retirement Board, which is enclosed with the Forms RL-11 and G-3EMP. The RRB field office enters the return address as well as the identifying employee information requested in the top portion of the Forms G-3EMP and RL-11 before they are released. After completing the G-3EMP, the employer mails it back to the RRB field office in the self-addressed return envelope.

The RRB proposes no changes to Form G-3EMP.

Form G-197, Authorization to Disclose Information to the Railroad Retirement Board, is used to obtain the consent of the applicant or annuitant for the release of medical information and related medical evidence/records to the RRB. The RRB requests an applicant or annuitant complete a separate Form G-197 for each medical source to be contacted. The completed Form G-197 is then enclosed with the particular request form sent to a medical source.

The Social Security Administration has a similar need for medical evidence to support disability claims. Form G-197 closely resembles SSA’s Form-827, Authorization to Disclose Information to the Social Security Administration. In addition, the consent statement contained on Form G-197 complies with the Health Insurance Portability and Accountability Act (HPIAA) and the special requirements for disclosure of treatment for drug abuse and/or alcoholism under the Drug Abuse Office Treatment Act and the Comprehensive Alcohol Abuse and Alcoholism, Prevention, Treatment, and Rehabilitation Acts.

The RRB proposes the following changes to Form G-197:

• Include educational records as a type of information subject to release.

• Add four additional sources from which to request information that may be pertinent to a disability determination

  • All educational sources (schools, teachers, records administrators, counselors, etc.).

  • Social workers/rehabilitation counselors.

  • Consulting examiners used by the Railroad Retirement Board.

  • Others who may know about my condition (family, neighbors, friends, public officials).

• Include in Item 6, insurance companies and workers’ compensation programs from which to request information.

• Other minor editorial changes.

Form G-250, Medical Assessment, is sent by an RRB field office to a disability claimant’s treating physician or consulting physician to obtain a medical assessment of the claimant’s ability to perform basic mental and/or physical work-related activities. The physician is asked to describe any limitations and cite specific medical findings. Form G-250 is transmitted to the treating physician with Form RL-250, Request for Medical Assessment, either:

• at the time of the initial application for a disability annuity or

• when making a determination concerning the continuance of a disability entitlement.

In some situations, the RRB may also request a consulting physician to conduct a medical examination of a disability claimant and report the examination findings on Form G-250. This is done when a disability claimant’s treating physician is not available or when the medical information provided by the treating physician in response to the Form RL-250 is incomplete or inconsistent.

Based on the impairments identified by the physician, Form G-250 obtains a medical assessment in one or more of the following areas:

• musculoskeletal system

• cardiovascular system

• respiratory system

• neurological system

• vision/hearing/speech

• mental functions

• other systems and impairments

• exertional restrictions

• environmental restrictions

The physician answers an initial Yes/No question as to whether there is an impairment or restriction in a particular system (for example, the Cardiovascular System), and if “Yes,” the physician (1) answers a series of related questions, (2) provides a brief synopsis of the medical findings, and, in some cases, (3) is asked to provide copies of specific medical records for inclusion with the form.

After completing the G-250, the physician signs it and returns it to the initiating RRB field office.

The RRB proposes the following changes to Form G-250:

• Request the patient’s social security number in Section 1 for better identification.

• Section 13

  • Add a certification and fraud statement

  • Request the doctor’s National Provider Number to improve the accuracy of provider identification and program integrity.

  • Add a return address field to identify where forms should be returned.

  • Add the Computer Matching and Privacy Protection Act Notice.

• Other minor editorial and cosmetic changes.

Form G-250A, Medical Assessment of Residual Functional Capacity, is used by the RRB Bureau of Hearings and Appeals (H&A) to assist hearings officers at the appeals stage of adjudication in making residual functional capacity (RFC) determinations which require a more precise level of information beyond merely that the claimant is limited in his ability to walk, sit, stand, etc.; information which may not be provided on the G-250. It is sent to a disability claimant's treating physician or to a consulting physician, along with a personalized cover letter, to obtain a medical assessment of the claimant's ability to perform basic mental and/or physical work-related activities. The physician is also asked to relate any limitations to specific medical findings.

Completion of Form G-250A is self-explanatory. The G-250A obtains a medical assessment of a claimant's RFC in one or more of the three following areas:

• Exertional restrictions for all claimants with physical impairments;

• environmental restrictions for all claimants as applicable; or

• mental restrictions for all claimants with mental impairments.

The physician indicates these restrictions through the use of check boxes provided on the form. Additional space is also provided for the physician to furnish a brief narrative relating the medical findings which support the restrictions assessed.

After completing the G-250A, the physician signs it and returns it to the initiating RRB field office.

Form G-250A is similar to and is modeled after Forms SSA-4734 and SSA-4734-F4-SUP, OMB No. 0960-0431.

The RRB proposes the following changes to Form G-250A:

Page 4

• Add a certification and fraud statement.

• Request the doctor’s National Provider Number to improve the accuracy of provider identification and program integrity.

• Other minor editorial changes.

Form G-260, Report of Seizure Disorder, is furnished by an RRB field office to a disability applicant or annuitant who indicates that the disabling condition includes seizures. The form is used to obtain evidence to support the claim of disability from the individual's personal physician. The items on Form G-260 are designed to guide the physician in furnishing medical information relating to the applicant's seizure disorder.

Completion of the G-260 is self explanatory. The identifying information is entered by the RRB field office before it releases the form. After completing the form, the physician mails it directly to the RRB field office.

The RRB proposes the following changes to Form G-260:

Page 5

• Add a certification and fraud statement.

• Request the doctor’s National Provider Number to improve the accuracy of provider identification and program integrity.

• Other minor editorial and cosmetic changes.

Form RL-11B, Request for Transcript of Medical Records, is furnished by an RRB field office to a private hospital to obtain records pertinent to the disability of an applicant or annuitant who is or was a patient at the hospital. The form is accompanied by Form G‑197, Authorization to Disclose Information to the Railroad Retirement Board.

Completion of Form RL-11B is self-explanatory. Identifying information, as well as a return address is entered by the RRB field office before release. After completing the form, the hospital mails it directly back to the field office.

The RRB proposes no changes to Form RL-11B.

Form RL-11D, Disclosure of Medical Records from a State Agency, is furnished by an RRB office to a state agency that pays workers' compensation or other public disability benefits to obtain medical evidence of an applicant’s or annuitant’s disability from a state agency that pays workers' compensation or other public disability benefits. In cases where the individual was, or is, hospitalized, hospital records will not be requested (Form RL‑11B), unless the evidence from the state has to be supplemented. The form is accompanied by Form G-197, Authorization to Disclose Information to the Railroad Retirement Board.

Completion of Form RL-11D is self-explanatory. Identifying information, as well as a return address, is entered by the RRB field office before release. After completing the form, the state agency mails it directly back to the field office.

The RRB proposes no changes to Form RL-11D.

Form RL-250, Request for Medical Assessment, is released by an RRB field office to a disability applicant’s treating physician to secure copies of all pertinent office records on the claimant’s treatment for at least the last 12 months, as well as copies of all available laboratory, hospital, and consultative reports. Form RL-250 also requests completion of Form G-250, Medical Assessment, which is enclosed along with Form G-197, Authorization to Disclose Information to the Railroad Retirement Board. Identifying information, as well as a return address, is entered by the RRB field office before release. Afterward, the treating physician mails any pertinent office records and the completed Form G-250 directly back to the field office.

The RRB proposes no changes to Form RL-250.

3. Planned use of improved information technology or technical/legal impediments to further burden reduction - The G-3EMP is being planned for conversion to electronic submission at some point. However, the minimal volume of the form relegates it a relative low priority. Forms G-250, G-250a, and G-260 are not practicable because they are initiated by the RRB and are part of a larger process that requires a face-to-face-interview. Forms RL-11B and RL‑11D are not practicable because they are initiated by the RRB with prefilled data.

4. Efforts to identify duplication -This information collection does not duplicate any other RRB information collection.

5. Small business respondents - N.A.

6. Consequences of less frequent collections - N.A.

7. Special Circumstances - N.A.

8. Public comments/consultations outside the agency In accordance with 5 CFR 1320.8(d) comments were invited from the public regarding the information collection. The notice to the public was published on page 63653 of the October 24, 2014, Federal Register. No comments or requests for additional information were received from the public.

9. Payments or gifts to respondents - None

10. Confidentiality - RRB-22, Railroad Retirement, Survivor and Pension Benefit System. In accordance with OMB Circular M-03-22, a Privacy Impact Assessment for this information collection was completed and can be found at http://www.rrb.gov/pdf/PIA/PIA-BPO.pdf.

11. Sensitive questions - The authorization to disclose was developed to better comply with the provisions regarding disclosure of medical and other information under P.L. 104-191 (the Health Insurance Portability and Accountability Act). Further, under 42 CFR Part 2, implementing the Drug Abuse Office Treatment Act and the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment, and Rehabilitation Act, information about treatment for alcoholism or drug abuse should not be disclosed without the patient's special consent. Under these regulations, the source is responsible for determining if, and to what extent, the information is relevant to the purpose for which it is being requested. Elements necessary for meeting both of these requirements are incorporated into Form G-197.

12. Estimate of respondent burden - The current burden for this collection is unchanged as follows:

Current Burden

Form Number	Annual Responses	Time (Minutes)	Burden (Hours)
G-3EMP	600	10	100
G-197	6,000	10	1,000
G-250	11,950	30	5,975
G-250A	50	20	17
G-260	100	25	42
RL-11B	5,000	10	833
RL-11D	250	10	42
RL-250	11,950	10	1,992
Tota	35,900		10,001

13. Estimate of annual cost to respondents or record keepers - N.A.

14. Estimated cost to the Federal Government - N.A.

15. Explanation for changes in burden - N.A.

16. Time schedule for data collection and publication - The results of this collection will not be published.

17. Request to not display OMB expiration date - The forms associated with this collection are seldom revised. Given the costs associated with redrafting, reprinting, and distributing the forms in order to keep the appropriate OMB expiration date in place, the RRB requests the authority to not display the expiration date on the forms.

18. Exceptions to Certification Statement - None

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