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Medical Source Statements allow Treating Physicians to provide Social Security with information on functional limitations

Note: the link for the medical source statement PDF download is at the end of this article.

As this website repeatedly states, though disability claims take into account both medical and vocational information, they are largely won on the basis of medical evidence. And one of the most powerful pieces of medical evidence is a medical source statement completed by a claimant's treating physician, a physician who has an established history of providing medical treatment and, therefore, is in a position to provide a statement as to a patient's prognosis and current functional limitations.

As this website also repeatedly states, most disability claims are decided via a 5 step sequential evaluation process in which a claimant's current level of functional limitations (known as their residual functional capacity, or RFC) is compared to the requirements of their past jobs in order to A) determine if they can return to their past work and B) determine, along with other vocational factors, such as age, work skills, and education, whether they have the ability to perform some type of other work which they have never done before.

In the Social Security Disability and SSI disability system, a mere diagnosis of a condition may mean relatively little. In most cases, the outcome of a case at any level (application, reconsideration, hearing) will depend on how the claimant's condition, or conditions, affects and limits their ability to engage in work activity, i.e. their residual functional capacity which can be measured by a medical source statement that is completed by a claimant's treating physician.

Why are medical source statements so effective? The answer is that they elicit the type of information from a treating physician regarding functional limitations that medical records will generally not address.

In fact, it seems to be fairly rare that a physician, after seeing a patient, will make any reference in their notes as to how their patient is functionally affected by their medical condition. Yet this is the type of information that Social Security seeks in order to render decisions.

And when this specific information is not found in a claimant's medical records (usually the case), then it is left to a disability examiner and that examiner's unit medical consultant (an M.D. who is employed by DDS, or disability determination services, to provide input and consultation to disability examiners in their case processing unit) to decide, based on their reading of the medical records, what a person's residual functional capacity is...despite the fact that neither individual will ever have met the claimant and the DDS medical consultant will be formulating an opinion on records that may themselves lack the expression of an opinion on the part of the treating physician.

To anyone's eyes, an opinion obtained from a physician who has actually seen and treated the patient/claimant would have considerably more validity. Despite this, Social Security does not attempt to obtain medical source statements from claimants. Therefore, claimants who wish to have considered the written opinions of their physicians as to their functional limitations must obtain such statements themselves. Unfortunately, when they do so, it is often the case that their physician, who likely has no understanding of how the disability system works, simply supplies a short statement indicating that their patient is disabled and unable to work, with no mention of functional limitations, thus rendering the doctor's statement practically useless.

The PDF download of this medical source statement example provides a good example of the type of information that should be obtained from a claimant's treating physician.

Note: this download will appear on a monitor as a low resolution scan of an existing document but should appear better in printed form.

Medical source statement example, PDF download

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