When you apply for Social Security, you’ll notice that medical information is mentioned often throughout the application and in other disability documents. This is because medical evidence is often the core of the Social Security Disability and SSI process. The Social Security Administration cannot make a decision on your claim without objective medical evidence. Here we will discuss five factors to consider while gathering medical evidence and what Social Security considers “credible evidence.”
Factor #1: Evidence must be from an “acceptable medical source.” Sources considered acceptable include licensed Medical Doctors, Optometrists, Podiatrists, Speech Pathologists, and Psychologists. Some exceptions may apply according to situation or location, but generally, if the medical practitioner is licensed, he or she is considered credible, though varying wieght may be given to their opinions.
Factor #2: Evidence should be from a “treating” source. This means that the medical practitioner who has been treating you consistently, over a period of time, probably knows you and your disability the best. Medical records from several doctors who have seen you once or twice won’t be very helpful to your disability claim. In addition, it may speed up the processing of your disability claim to have solid medical records from one (or two) source(s), and it may mean you won’t have to see a Social Security doctor. Simply put, it is important to visit your doctor frequently and over a long period of time if possible.
Factor #3: Evidence from other health facilities if applicable. These health facilities include hospitals, clinics, and other sources you may have visited in regards to your disability. Social Security likes to have everything in your file before your case is considered, even if the records contain little valuable information. If you withhold medical records because they seem unimportant, Social Security may wonder if you are hiding something that may hurt your claim. They also have you complete medical authorizations for the purposes of requesting your medical records, so even if you do not supply these records, Social Security should acquire them, though the agency does not always order important records. You have to check your own file. Thus it is best to provide all the information you can, and to request it all yourself to save time if possible. Do not submit duplicate records.
Factor #4: Evidence from non-medical sources and other practitioners. This includes evidence regarding your ability to work obtained from social workers, schools, family members, employers, and practitioners (considered non-medical by Social Security) such as chiropractors, audiologists, and herbal doctors.
Evidence from these sources can be helpful, but again, the medical records are the primary source of evidence and information that will be used to determine your disability claim.
Factor #5: What information in medical records should be included? The Social Security Administration especially looks for medical history; clinical findings (i.e., results of physical or mental status exams); laboratory findings (blood pressure, x-rays, etc.); diagnosis; treatment prescribed with response and prognosis;and a statement providing an opinion about what the claimant can still do despite his or her impairment(s), based on the medical source’s findings on the above factors.
This statement is often very helpful in your disability claim. It is important to get the right information from your doctor to describe your limitations. Make sure the doctor includes any applicable information such as ability to perform work-related activities (such as sitting, standing, walking, lifting, carrying, handling objects, hearing, speaking, and traveling). In cases involving mental impairments, the report should describe your ability to understand, to carry out and remember instructions, and to respond appropriately to supervision, coworkers, and work pressures in a work setting.
If you have insufficient medical records, Social Security usually may set up a Consultative Exam for you with an outside source chosen by Social Security. Remember that this exam is for Social Security’s purposes and is not intended to give you ongoing care and treatment. Also remember that these doctors are very careful about giving the opinion of an individual being “disabled.” Thus it is more beneficial to see your own doctor often and over a long period of time even before applying or during the process to avoid this situation. Wherever you are in the disability process, best of luck.
The fine print: As an important formality, be aware that we do not represent any person until we both agree in writing that we will represent you. Meeting all time limits and deadlines imposed by the law remains your responsibility until we have a written agreement. If you wish a no fee consultation on your Social Security Disability matter call or email is, or fill out the interactive form on the Seegerlaw.com web site.