The Medical Records That Are Best For Your Disability Claim

If you are filing for Social Security Disability (SSD) or SSI, you will need medical evidence to back up your claim, and medical records that supply a complete, accurate picture of your medical condition can, in the best case scenario, eliminate the need for a disability examiner to gather any additional medical information before making a decision. In short, if your medical records are in order you should receive a timely response on your claim.

The best medical records for SSD and SSI disability are 1. those that are current and 2. those that show how your condition limits your ability to work. How current should your medical records be? To prove your claim as well as prove when your disability began, you obviously need older records from the time of your disability onset (note: proving your disability as far back as possible can have a dramatic effect on how much back pay you get). But, you also need at least some records that are not older than 90 days.

What if you don't have current records?

If a disability examiner or an Administrative law judge at a disability hearing does not have at least some documentation from the last 90 days, you will need to be scheduled for a Social Security examination, or consultative exam, called a CE. Typically, the only purpose of a CE is get a recent "snapshot" of your condition so the case can be decided. A CE tends to be a very short exam, performed by an independent physician who is paid by Social Security and who has likely never seen you, and knows practically nothing about you. Obviously, it would be preferable if your "most recent medical records" came from your own doctor. Therefore, if you are filing for disability or have an appeal, make sure you are seen regularly by your doctor(s).

Records from your own doctor or doctors

Social Security prefers that disability claims be supported by medical records from the applicant's treating physician (regular doctor). In general, the treating physician--someone who has a history of treating you--is in a better position to document the onset date of the impairment, how it can be expected to progress over time (prognosis), as well as any physical or mental limitations it places on the patient's ability to work.

What are acceptable medical records?

Medical records from hospitals, clinics, etc., are also valid forms of documentation, provided that the individual signing off on any reports from these treatment sources is considered to be acceptable. Social Security recognizes the medical opinions of licensed MDs, DOs (osteopaths), psychologists and optometrists. It does not give any weight to the opinions of chiropractors, although a disability examiner may review any x-rays or other medical tests ordered by chiropractors before making a decision.

However, disability examiners tend to pay closer attention to the opinion of long-time treatment sources than those that result from a short hospital stay or visit to the ER. The best medical records to support a disability claim are those from a physician with whom the patient has a longstanding relationship.

In some instances, often due to financial constraints or lack of health insurance altogether, the claimant has not received regular or recent medical treatment for his condition, in which case the disability examiner will order a consultative exam, or CE.

Social Security Medical exams

Consultative exams can be physical or psychological, or psychiatric, and are meant only to provide the disability examiner with an overview of the claimant's current medical condition. These exams are brief, and as there is no relationship between the patient and the physician performing the exam, they seldom provide an examiner with more than the most basic understanding of any limitations an individual has due to his impairment.

If you are filing for disability, be sure to include medical records from any place in which you have received medical treatment for your impairment. Medical records from your treating physician, if you have one, are best, but don't leave out any medical records from past or present acceptable medical sources. A consultative exam is better than nothing, but it is no substitute for a medical opinion from your doctor that supports your claim for disability.

About the Author: Tim Moore is a former Social Security Disability Examiner in North Carolina, has been interviewed by the NY Times and the LA Times on the disability system, and is an Accredited Disability Representative (ADR) in North Carolina. For assistance on a disability application or Appeal in NC, click here.

Most popular topics on SSDRC.com

Social Security Disability in North Carolina

Common Mistakes to avoid after being denied for Disability

Tips to Prepare for Filing for Social Security Disability or SSI

Advice to Win SSD and SSI Benefit Claims

Social Security Disability SSI Questions

What is the difference between Social Security Disability and SSI?

How to get disability for depression

Getting disability for fibromyalgia

SSI disability for children with ADHD

What is the Application Process for Social Security Disability and SSI?

Social Security Disability SSI Exam tips

More Social Security Disability SSI Questions

What makes you eligible for Social Security Disability or SSI?

Related pages:

What is the fastest decision I can get for SSDI?
When should you file an appeal for SSI or SSDI?
How Far Back Does Social Security Look At Your Medical Records?
Does Social Security Disability prefer Current Medical Records?
Medical Records That Are Best For Disability Claim
Will SSD or SSI Disability Be Based On Newer Or Older Medical Records?
Medical Evidence for Social Security Disability
Why does it take so long for Social Security to get medical records?
Recent Medical Records for a Social Security Disability or SSI case
Including medical reports with the application for disability
How do medical records and work history determine a disability claim?
What if the disability examiner cannot find all the medical records?
Qualifying for disability in California
How do I apply for disability in Benefits in California
Applying for Disability in California