UNITED STATES RAILROAD RETIREMENT BOARD - 1

Program

Letter

United States

Railroad Retirement Board

Office of Programs

Quality Reporting Service Center

Email: QRSC@rrb.gov

Phone: (312) 751-4992

 Fax: (312) 751-7123

Letter No. 2017-02 Date: January 31, 2017

 [Revised February 10, 2017] 

CONTACT: Lavette Fargo PHONE: (312) 751-4617

 Policy and Systems 

 EMAIL: Lavette.Fargo@rrb.gov

TO: Chief Executives Officers and Medical Contact Officials

SUBJECT: New Form RL-11D1, Request for Medical Evidence from Employers 

This applies to Disability Applicants only.

Please share this notice with all individuals within your organization who are responsible 

for medical matters.

Effective February 1, 2017, the Railroad Retirement Board (RRB) will ask employers (covered 

and non-covered) to furnish copies of any medical records that you may have on the employee 

within the last 18 months. Attached is a copy of the new Form RL-11D1, Request for Medical 

Evidence from Employers (https://www.rrb.gov/pdf/aandt/pl17-02_Attachment.pdf). Form 

RL-11D1 is a newly created letter used in initial filing for disability applicants or any time medical 

records are necessary to assist the RRB in determining whether disability benefits are payable. 

The form will be mailed by an RRB field office and it will be accompanied with a copy of the 

applicant’s signed Form G-197, Authorization to Disclose Information to the Railroad Retirement 

Board. The certifying official should return Form RL-11D1 to the Disability Benefits Division 

certifying that they have attached medical evidence or that they have no medical evidence for the 

employee. The official should also sign, date, and provide their contact information.

For Questions and Answers (Q&A) regarding the new Form RL-11D1, go to 

http://www.rrb.gov/aandt/pl/pl1702_Q&A.asp. 

If you have additional questions, please contact the individual listed on the top of this program 

letter. 

Attachment
RRB Form RL-11D1 (99-99)

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:

 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,

Jane Doe

Claims Representative

Enclosure

 Form G-197

Form Approved 

UNITED STATES OF AMERICA OMB No. 3220-0038

RAILROAD RETIREMENT BOARD

OFFICE OF PROGRAMS/POLICY & SYSTEMS

844 NORTH RUSH STREET

CHICAGO, IL 60611-1275

WWW.RRB.GOV

OFFICE HOURS: M-T-TH-F 9:00 AM TO 3:30 PM TOLL-FREE NUMBER: 1-877-772-5772

WEDS. 9:00 AM TO 12:00 PM - CLOSED FEDERAL HOLIDAYS 

John S. Smith

Human Resources

Any Railroad Employer

123 Main Street

Any Town, IL 60000

Month DD, YYYY

In reply refer to

Thomas Trainman

A XXX-XX-XXXX

Dear Mr. Smith:

ATTACHMENT
RRB Form RL-11D1 (99-99)

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.

Signature of Employer or Authorized Official Month Day Year

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: Associate Chief Information Officer for

Policy and Compliance, Railroad Retirement Board, 844 North Rush Street, Chicago, IL 60611-1275.
Program Letter 2017-02

Questions and Answers (Q&A)

* NOTE: Form RL-11D1 applies to Disability Applicants only.

1

1. Is the Railroad Retirement Board (RRB) requesting medical information beyond the 

scope of the disability reason given by the employee when requesting benefits? 

No. Form RL-11D1 is a newly created letter used in initial filings for disability applicants. 

Before deciding whether or not an employee applicant is disabled, the RRB develops a 

complete medical history. This allows the RRB to understand how an impairment affects 

the employee’s ability to work, and includes information from railroad and non-railroad 

employers. Guidance about this process and the underlying authority may be found in the 

Code of Federal Regulations (CFR) CFR §220.45(b) and §220.46(e)(4).

2. A railroad (RR) and the RRB are not necessarily covered entities in connection with

health information privacy (HIPPA). Should we assume that the employer consent is 

required to provide the medical records to the RRB, but the employee does not have 

to give consent for the RR to distribute their medical information to the RRB? 

No. The consent of the employee, not the employer, is required to provide medical records 

to the RRB.

 

3. Does the RRB obtain consent from the employee who is filing for disability coverage 

prior to sending this letter out to the employing RR?

Yes. The employee completes and signs, Form G-197, Authorization to Disclose 

Information to the Railroad Retirement Board, when filing a disability application with the 

RRB which gives consent for the RRB to obtain any medical and educational records for 

the employee. The employee’s signed Form G-197 is sent as an attachment with the Form 

RL-11D1.