Necessary Medical Evidence for Social Security Disability Claims

In order to win social security disability benefits, you'll need evidence to back up your claim that you can't work.

When you file a disability claim with the Social Security Administration (SSA), you are required to provide medical evidence showing you have a disability and demonstrating how severe it is. Social Security will request records for you from your treating physicians and hospitals if you sign a release. It can be helpful to contact your treatment professionals to let them know to expect this request.

Your Treatment Providers

SSA places special weight on evidence from the doctors who are currently treating you because they tend to know your medical history in more detail than other sources (such as a Social Security doctor who sees you one time). Treating doctors can provide an opinion about your condition that may be much more persuasive than your medical records alone.

Submitting evidence directly to SSA from your primary treatment providers can help move your claim more quickly through the system. SSA will send them a medical assessment form to complete; remind your doctors of the importance of completing this. A primary treatment provider's assessment is one of the most influential pieces of evidence you can submit in support of your claim. It is also to your advantage to ask your primary treatment providers to write a letter to accompany the medical records and reports they submit to SSA. The letter should contain your doctors opinion on what you can and cannot do, and why.

If you're doctor won't assist you, here are some tips that may help.

Preferred Types of Treatment Providers

SSA considers certain treatment providers as “acceptable medical sources.” These include licensed physicians (not chiropractors, licensed or certified psychologists including school psychologists (for limited purposes only), licensed optometrists, licensed podiatrists, and qualified speech-language pathologists. You can help your claim by submitting as much evidence as possible from these preferred treatment providers. Or, if you are relying on SSA to gather the medical evidence, give them a complete list of all of your providers.

Hospitals

SSA will also request information from any hospitals where you have been treated. If you are relying on SSA to gather this medical information for you, be sure to provide a complete lists of hospitals where you have been seen in the emergency room and/or admitted.

Types of Records to Submit

Medical records and reports should include:

  • a history of your medical problems and diagnoses
  • the results of clinical exams
  • laboratory findings (such as x-rays)
  • current diagnoses of disabling conditions
  • prescribed treatment, your response to the treatment, and your prognosis
  • a statement from the treatment provider about what you are still able to do in spite of being disabled, based on the medical findings listed above, including information on your:
    • Work-related mental ability. Your doctor's statement should describe your ability to understand and carry out instructions, to concentrate, to adapt to changes, and to respond appropriately to supervision, coworkers, and work pressures in a work setting.
    • Work-related physical ability. The statement should describe your ability to perform basic physical work-related activities such as standing, walking, lifting, carrying, handling objects, sitting for extended periods, hearing, speaking, and traveling.

Test Results

Certain types of claims require you or your doctor to submit test results in order to get approved. For example, when submitting a claim for coronary heart disease, you must submit evidence of a stress test, imaging (such as an angiogram), and ECGs (electrocardiograph or electrocardiograms) results.

It is important to know what tests, if any, are required for your condition for SSA to approve your claim. See our articles about requirements and tests for specific disabilities for additional information about proving your claim.

Evidence of Your Limitations

Social Security also considers evidence pertaining to your symptoms that affect your ability to function, such as pain and fatigue. Limitations on your daily activities, factors that trigger your symptoms to occur or make them worse, affects of medications you take to manage your symptoms, the frequency and intensity of your symptoms, and any measures or treatments you use to manage your symptoms will be taken into consideration. This information will be provided to Social Security by you and your treatment providers.

Other Evidence

While medical evidence from your doctors will be the most persuasive to SSA, and is critical to your claim, evidence from other sources can help to explain the affects of your disability on your daily functioning. Information from social workers, employers, physical therapists, and alternative treatment providers such as chiropractors can help your claim. If the claim is for a child, information from schools, teachers, parents, and caregivers can be useful.

Consultative Exams

Do not be alarmed if you receive a request from Social Security to attend a "consultative exam." These exams are routinely requested when disability claims examiners feel they need additional medical evidence to decide your claim. Often Social Security sends you for a consultative exam with a doctor that the claims examiner selects. You have the right to request that your regular doctor perform this exam. However, if your treating physician is for any reason not considered qualified to conduct the exam, or doesn’t have medical equipment needed to perform required tests, you may have to see the new doctor selected by Social Security.

Likewise, if Social Security asks you to see your regular physician for the exam and you have a legitimate reason you prefer to see another doctor, let them know. But bear in mind that your physician usually knows your medical history so well that he or she can provide much stronger support for your disability claim than a doctor who spends one short visit with you.

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