G-250 (08-15). Form Approved OMB No. 3220-0038-2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Section 1, where you will find instructions on which items may not apply to you. Follow any 'Go to' directions provided.
3. In Section 2, enter the Patient Identification details including Railroad Retirement Claim Number, Social Security Number, Name, Address, and Telephone Number.
4. Proceed to Section 3 for General Information. Fill in the dates of treatment and last examination along with the patient's weight and height.
5. In Section 4, assess the Musculoskeletal System. Mark 'X' for normal or describe any impairments as instructed. Attach relevant reports if necessary.
6. Continue through Sections 5 to 12 by marking appropriate boxes and providing detailed descriptions of cardiovascular, respiratory, neurological systems, and any exertional or environmental restrictions.
7. Finally, complete Section 13 by certifying the information provided is correct. Ensure your signature is included before submission.

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