RL-11D1 Request for Medical Evidence from Employers

Form Approved
OMB No. 3220-0038

UNITED STATES OF AMERICA

RAILROAD RETIREMENT BOARD

PROPOSED

WWW.RRB.GOV
OFFICE HOURS: 9:00 AM TO 3:30 PM
MONDAY THROUGH FRIDAY EXCEPT FEDERAL HOLIDAYS

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

In reply refer to

The employee named above has applied for disability benefits with the Railroad Retirement Board
(RRB). To assist us in determining whether such benefits are payable, please furnish this office
with any medical records you have on the employee within the last 18 months. Examples of
records include, but are not limited to:
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




Fitness for duty examinations;
Transcripts of in-hospital and out-patient treatment;
Transcripts of examinations for compensation or pension;
Hospital admission and discharge summary; or
X-ray or laboratory reports.

Authorization from the employee to release the medical information is enclosed. This is not an
authorization to conduct a new examination.
Please complete, sign, and return the next page to the RRB within 30 days from the date of this
letter.
Sincerely,

Enclosure
Form G-197

RRB Form RL-11D1 (xx-xx)

Form Approved OMB No. 3220-0038

UNITED STATES RAILROAD RETIREMENT BOARD - 2

Please enter an “X” in the appropriate box:

 We do not have any medical records for the employee named above.
 We have attached medical records for the employee named above.
CERTIFICATION

I certify that the information I gave the Railroad Retirement Board (RRB) on this form is true to the best of my
knowledge. I know that if I make a false or fraudulent statement or withhold information from the RRB, I am
committing a crime under Federal law, which may be punishable by fines, imprisonment, or both.
Month
Day
Year
Signature of Employer or Authorized Official
Title of Employer or Authorized Official
Area Code

Business Telephone Number

Business Address (Number and Street)

Please return this form and any medical records to:
US RAILROAD RETIREMENT BOARD
Disability Benefits Division
844 North Rush Street
Chicago, IL 60611-1275

PAPERWORK REDUCTION ACT NOTICE
The information requested on this form is authorized by Section 7(b)(6) of the Railroad Retirement Act and is
needed to provide information necessary to complete processing for the claimant named and to determine
the claimant’s entitled to disability benefits under the Railroad Retirement Act. If you fail or refuse to furnish
the requested information, non-payment of the annuity to the claimant may result.
We estimate this form takes an average of 20 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: Chief of Information Resources
Management, Railroad Retirement Board, 844 North Rush Street, Chicago, IL 60611-1275.

RRB Form RL-11D1 (xx-xx)