The Medical Evidence Used on a Social Security Disability or SSI Claim

Social Security Disability (SSD) and Supplemental Security Income (SSI) benefits are awarded to those who, due to a severe physical or mental impairment, are unable to earn a substantial, gainful wage.

Thus, the focus of the disability examiner deciding a claim is not just whether a claimant is impaired, but whether the impairment is severe and long lasting enough to prevent the claimant from performing any type of work at which he or she might earn a living.

Related: How severe must your condition be before you can be awarded disability benefits?.

Decisions are based on Medical Evidence

The only way for a disability examiner to make this determination on a claim is by reviewing the claimant's medical evidence i.e. medical records. Ideally, by the time one files for disability he or she has already received treatment from at least one acceptable medical source.

It's important to note here that, in the eyes of the SSA, not every medical treatment source is acceptable. Licensed physicians, psychiatrists, and psychologists are acceptable sources, and their medical records can be used to help prove a claim for disability. Chiropractors, acupuncturists, massage therapists, etc., are not acceptable medical sources, and opinions from these individuals will not carry any weight with the examiner.

If you are considering filing a claim for disability, your best course of action is to document your symptoms and diagnosis by seeing a licensed physician (or mental health professional, if the basis of your claim is a mental disorder). Try to see a doctor who is a specialist in the field for your particular type of disorder.

For instance, an orthopedic doctor for back or neck pain, or a doctor who specializes in pain management (some anesthesiologists perform this type of treatment now, as well as physicians who specialize in physical and medical rehabilitation), and a psychiatrist for treatment of severe depression, bipolar, etc. While records from your family doctor will prove useful, they may not be as helpful to your case as an opinion from a medical specialist.

In addition to ensuring that you have enough medical evidence to back up your claim, you should also provide Social Security with correct contact information for any medical facility from which you have received treatment. Far too often it takes a disability examiner several months to receive records from physicians, which can only delay a decision on your claim. Be sure that you have supplied Social Security with correct names, addresses, and phone numbers to ensure that this part of the process goes as smoothly as possible.

When determining the medical evidence you will submit for your SSD or SSI application, doctor's notes from ER visits, clinics, etc., should not be overlooked. Any results from medical tests that support your claim, such as MRIs, CAT scans, X-rays, lab tests, or any mental exams performed by a psychiatrist or psychologist are valid sources of medical evidence and should be included in your file.

There's one final thing to keep in mind about medical records, and that is, even if you have received treatment for several years for your impairment, the records may not state that you are unable to work. Why? Because physicians generally keep notes for themselves rather than for disability examiners. They are concerned with a patient's physical or mental health, rather than that patient's ability to work.

So, if you are filing for SSD or SSI, it's a good idea to make this known to your treating physician. In this way you can determine if your physician is inclined to help your claim, or will be of no help because a) he doesn't want to bother with it; or b) he does not believe you cannot work.

If you find that this is your physician's attitude or belief system, the best thing you can do is find a more sympathetic physician. No one wants to doctor shop, but realistically, if your physician is unwilling to state you are disabled, it looks bad for your case.

If your physician is willing to support your claim for Social Security Disability, then you should probably go one step further and ask the physician to be sure your records include three important pieces of information: 1) Your date of onset (when symptoms first began to be disabling); 2) your current level of disability; and 3) your prognosis (if your condition is likely to improve, stay the same, or worsen over time).

You could also ask your physician to fill out an RFC form, which details your residual functional capacity (what you can or cannot do in light of your impairment). These forms are pretty basic, and shouldn't take a physician more than 10 or 15 minutes to complete.

The benefit of an RFC is that it tells the disability examiner (or judge if you have appealed your claim to the hearing level) exactly what you are physically or mentally capable of doing. It's a lot easier to understand for most non-medical professionals than doctor's notes or medical records, and thus could be very instrumental in winning a claim for disability.

Note: if you have representation (a disability lawyer), this individual will usually try to obtain an RFC form from your treating physician at the time of a disability hearing.

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.

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