Social Security Disability Resource Center
Medical Evidence Used on a Social Security Disability or SSI Claim
Social Security Disability (SSD) and Supplemental Security Income (SSI) 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?.
The only way for a disability examiner to make this determination on a claim is by reviewing the claimant’s 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.
Social Security Disability and SSI Resource Center
The Most Basic questions about Getting Disability Benefits
Social Security Disability and SSI Back Pay Benefits
Social Security Disability SSI and whether or not you can work
How long does it take for Social Security Disability or SSI?
Social Security Disability SSI Awards and Award Notices
Tips, Mistakes, How to Qualify, and How to Win Disability
Tips and Advice for Social Security Disability and SSI Claims
Common Mistakes to avoid after being denied for Disability
Disability Qualifications and How to Qualify for Disability Benefits
Winning Social Security Disability or SSI, How to Win
Denials, Appeals, and Getting a Disability Lawyer or Representative
What you should know about Social Security Disability and SSI Denials
Social Security Disability and SSI Appeal Process - How to file appeals
Questions about Disability Lawyers and Hiring a Disability Attorney
Various Types of Benefits including SSI, Mental, and Child benefits
SSI Disability Benefits, Questions and Answers
Social Security and SSI based on Mental Disability
Social Security Disability or SSI Benefits for Children
Disability Benefits through Social Security
Information to start with regarding Disability Claims
An Overview of Social Security Disability and SSI
What is considered a Disabling condition by Social Security?
The Disability Requirements to be eligible for SSD and SSI Benefits
Filing for Social Security Disability or SSI Benefits
Social Security Disability and SSI Applications
Social Security Disability SSI List of Conditions and Impairments
Social Security Disability SSI: Medical Evidence and Records
Filing your claim for disability benefits
Eligibility for receiving disability benefits
Resources on this site
Social Security Disability, SSI Terms and Definitions
Previously answered questions regarding SSD and SSI
About the Author of SSDRC, Tim Moore
The SSDRC Disability Blog
For Individuals living in North Carolina
Disability in North Carolina
North Carolina Disability Lawyer
Getting disability in North Carolina
Social Security Denied Me But Didn’t Have All My Medical Records?
How Can You Get Medical Records For A Disability Case without Insurance?
Can you be denied disability if social security cannot find your medical records?
Social Security Disability Medical Records
How Far Back Does Social Security Look At Medical Records for SSDI SSI?
Social Security Disability, Medical Records, and a Person's Limitations
Medical Evidence on a Social Security Disability or SSI Claim
Getting your medical records can speed up your disability claim
Will a Disability attorney try to Help You get Your Medical Records?
SSI disability and monthly mortgage payments
Information on the following topics can be found here: Social Security Disability Questions and in these subsections:
Frequently asked questions about getting Denied for Disability Benefits | FAQ on Disability Claim Representation | Info about Social Security Disability Approvals and Being Approved | FAQ on Social Security Disability SSI decisions | The SSD SSI Decision Process and what gets taken into consideration | Disability hearings before Judges | Medical exams for disability claims | Applying for Disability in various states | Selecting and hiring Disability Lawyers | Applying for Disability in North Carolina | Recent articles and answers to questions about SSD and SSI
These pages answer some of the most basic questions for individuals who are considering filing a claim.
Filing for disability - How to file for SSD or SSI and the Information that is needed by Social Security
How to Apply for Disability - What medical conditions can you apply and qualify for?
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?
How to Prove you are disabled and qualify to win disability benefits
How do you prove your disability case if you have a mental condition or impairment?
Social Security Disability Back pay and How Long it Takes to Qualify for it and receive it
Social Security Disability SSI - Eligibility Requirements and Qualifications Criteria