RL-11B Disclosure of Hospital Medical Records

Form Approved
OMB No. 3220-0038

UNITED STATES OF AMERICA

RAILROAD RETIREMENT BOARD
OFFICE OF PROGRAMS/POLICY & SYSTEMS
844 NORTH RUSH STREET
CHICAGO, IL 60611-1275
WWW.RRB.GOV

OFFICE HOURS: 9:00 AM TO 3:00 PM
MONDAY THROUGH FRIDAY EXCEPT FEDERAL
HOLIDAYS

,
ATTENTION: MEDICAL RECORDS DEPT.

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

In reply refer to
Name:
RRB Claim No.:

The above-named patient or former patient of your hospital has applied for or is receiving disability
benefits under the Railroad Retirement Act. To assist us in determining whether such benefits are
payable, please furnish this office copies of any admission and discharge summaries with diagnoses,
emergency room records, clinical findings, and laboratory and X-ray reports. DO NOT SEND DAILY
CHART NOTES UNLESS OTHERWISE INDICATED.
Since the Railroad Retirement Board is an agency of the United States Government, the
information should generally be furnished without charge as it is needed to establish
entitlement to benefits under a federal law. If you are unable to provide the records without
charge, please contact ________ before billing.
Your cooperation in furnishing the required information as soon as possible will be appreciated.
Please include the above RRB claim number in your reply. Authorization to release medical
information is enclosed.
Enclosure: Form G-197
_______________________________________________________________________________
IDENTIFYING PATIENT INFORMATION
NAME AND ADDRESS AT TIME OF ADMISSION OR
TREATMENT

PATIENT’S SSN

Inpatient
DATE OF BIRTH

ADMISSION/TREATMENT
STARTING DATE
NATURE OF DISABILITY

DISCHARGE/TREATMENT
ENDING DATE

CLINIC/PATIENT NO.

Outpatient
ATTENDING PHYSICIAN

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: Associate Chief Information Officer for Policy and Compliance, Railroad Retirement Board, 844 North Rush
St., Chicago, IL 60611-1275.

RRB Form RL-11B (01-21)