RL-11B Disclosure of Hospital Medical Records

Form Approved
OMB NO. 3220-0038

ATTENTION: MEDICAL RECORDS DEPT.

In reply refer to
Name:
RRB Claim No.:
The above-named atient or former patient of your hospital has applied for or is receiving disability
benefits under the ailroad Retirement Act. To assist us in determining whether such benefits are
payable, please furnish this office copies of an admission and discharge summaries with dia noses,
emer enc room records, clin~calfindin s, an laboratory and X-ray reports. DO NOT SEND AlLY
N~TES
UNLESS OTHERWIS? INDICATED.

W

d"

CHAWT

%

Since the Railroad Retirement Board is an agency of the United States Government, the
information should enerally be furnished wlthout charge as it IS needed to establish
entitlement to bene its under a federal law. If you are unable to provide the records without
charge, please contact
before billing.

9

Your cooperation in furnishiu the required information as soon as possible will be appreciated.
Please include the above RR claim number in your reply. Authorizat~onto release medical
information is enclosed.

B

Enclosure: Form G-197
IDENTIFYING PATIENT INFORMATION
NAME AND ADDRESS AT TIME OF ADMISSION OR
TREATMENT

PATIENT'S SSN

Inpatient
DATE OF BIRTH

Outpatient
I

ADMlSSlONmREATMENT
STARTING DATE

DISCHARGERREATMENT
ENDING DATE
I

NATURE OF DISABILITY

CLlNlClPATlENT NO.

A'ITENDING PHYSICIAN

I

OTHER PATIENT INFORMATION (BLDG., CLINIC, DEPT., ETC.)

PAPERWORK REDUCTION ACT NOTICE
We estimate this form takes an average of 10 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: Chief of Information Resources Management, Railroad Retirement Board, 844 North Rush St., Chicago, IL
6061 1-2092.

RRB Form RL-1 1B (09-05)