Medical Documentation

 

As you could imagine, the SSA needs you to be able to prove to them that your condition is debilitating and prevents you from being able to achieve sustainable gainful activity (SGA) before they begin sending you a monthly disability check. To prove your disability, the SSA requires you to send all medical documentation and evidence that is relevant to your disability from all your doctors and medical specialist.

 

Acceptable Medical Sources

The SSA regulates the sources of your medical documentation to make sure it came from a medical professional or an “acceptable medical source.” Once the SSA confirms your sources of medical documentation are valid, all documentation you gave the SSA will be considered while determining whether or not you qualify for disability benefits. Below are the medical sources the SSA considers acceptable:

  • Licensed physicians (medical or osteopathic doctors)
  • Licensed or certified psychologists (such as school psychologists)
  • Licensed optometrists (for visual disorders only)
  • Licensed podiatrists (typically for foot and/or ankle impairments only)
  • Qualified speech-language pathologists (speech or language impairments only)

 

Evidence From Your Treating Doctor

The Social Security Administration is required to give your treating doctor’s opinion more weight in the decision to award or deny you disability benefits. The SSA knows that your treating doctor will have a better and more informative opinion about your condition than a medical consultant since he or she has been consistently giving you medical attention for your disability. Administrative law judges (ALJ) are also required to give your doctor’s opinion more weight during an appeals hearing.

Out of all the medical documentation you provide, the SSA is required to give more weight or consideration towards your treating physician’s opinion and reports. The SSA makes the assumption that your treating physician will have a more informative opinion about your impairment than a medical consultant from the DDS. This is due to the fact that your physician has been treating your condition for a length of time while a medical consultant has one chance to review your condition.

 

Medical Reports

In several instances, the SSA will ask your treating physician, doctors, psychologists and/or any other medical specialist to provide a medical report(s) on the applicant’s condition. Typically applicants should submit these reports with the initial application to prevent this from happening. This is because it takes time for your physicians to fill out the documentation and send it to the SSA, which can potentially delay the application process by a few weeks to a couple months. When a doctor fills out a medical report, it is important they include the following:

  • Clinical and laboratory findings
  • Treatment prescribed with applicant’s response
  • Diagnosis of condition
  • Prognosis of condition
  • Detailed medical history
  • List of applicant’s functional limitations due to condition
  • If 18 years old or older: applicant’s ability to perform work-related activities despite their condition.
  • If younger than 18 years old: applicant’s functional limitations compared to child his or her age.

 

Timely, Accurate, and Adequate Medical Evidence

Providing the Social Security Administration with timely, accurate, and adequate medical evidence will not only increase your chances for approval for your initial application but also will also greatly reduce or potentially eliminate the need for the SSA to gather additional medical documentation from your doctors and typically will speed up the application process.

Timely records: The SSA prefers that you have “timely” or recent, up-to-date medical evidence on your condition. This means the medical evidence is no older than six months old. Older documentation and records are still very important, as the SSA likes to see “longitudinal” medical records (medical evidence from your medical history) when determining the severity of your condition. Longitudinal medical records are necessary for approval of retroactive disability back pay in SSDI cases.

Accurate records: All medical records that correctly describe your condition. If the SSA finds inconsistent records among your medical documents, they will not consider the evidence during evaluation since the evidence was deemed inaccurate. For example, if your treating doctor’s records indicate you can not pick up objects weighing 10 pounds or more but another exercise record states you can pick up weight well over 10 pounds, the SSA will not consider the evidence.

Adequate records: Are medical records that have enough accurate, detailed information for the SSA to be able to confidently make a medical conclusion about your functional limitations and the severity of your condition. If the SSA believes your medical records are not adequate enough, the SSA will either request more evidence from your doctors or will ask you to attend a consultative exam.

 

Consultative Examinations

If the medical documentation you provided is insufficient enough for the DDS disability examiner to determine if he or she qualifies for disability benefits, the SSA will request that you attend a consultative medical exam. Your treating physician is the preferred source for a consultative exam as long as he or she is qualified. Although the SSA’s restrictions may call for an independent source to perform your consultative examination if:

  • Your treating doctor refuses to perform the exam.
  • Your treating doctor does not have the necessary equipment to perform the exam.
  • There are inconsistencies within the provided documentation from your treating doctor (thus lowering their reliability).
  • You have another doctor you rather have perform the examination with good justification as to why.
  • The SSA knows or finds that your treating doctor is not a “productive” source of medical information.