WHAT ARE THE BEST MEDICAL RECORDS FOR A SOCIAL SECURITY DISABILITY CLAIM?



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 applicants 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 patients 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 claimants 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 dont 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.







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These pages answer some of the most basic questions for individuals who are considering filing a claim.

Can you get temporary Social Security Disability or SSI benefits?

Permanent Social Security Disability

What is the difference between Social Security Disability and SSI?

Who is eligible for SSI disability?

Can I Be Eligible For SSI And Social Security Disability At The Same Time?

What makes a person eligible to receive disability benefits?

Applying for Disability - How long does it take to get Social Security Disability or SSI benefits?

What happens if I file a disability application and it is denied by a disability examiner or Judge?