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.

By , Attorney · Northeastern University School of Law

When you file a disability claim with the Social Security Administration (SSA), you're required to provide medical evidence that shows you have a disability and that demonstrates how severe it is.

But you don't have to copy the medical records yourself. Social Security will request records for you from your physicians and any clinics or hospitals you've visited, if you sign a release. It can be helpful to contact your doctors to let them know to expect this request.

Medical Records From Your Treatment Providers

Medical evidence from the doctors who are currently treating you can be persuasive to Social Security, because your doctors tend to know your medical history in more detail than other sources, such as a Social Security doctor who sees you one time at a "consultative exam" (more on this below). Treating doctors can provide an opinion about your condition that may be more convincing than your medical records alone.

For key results, submitting evidence directly to the SSA from your primary treatment providers can help move your claim more quickly through the system. Social Security will send your doctors a medical assessment form to complete, but you may need to remind your doctors of the importance of completing this.

A doctor's assessment is one of the most influential pieces of evidence you can submit in support of your claim. It's to your advantage to ask your doctor to write a letter to accompany the medical records and reports they submit to the SSA. The letter should contain your doctor's opinion on what you can and can't do, and why.

If your doctor won't assist you, here are some tips for filing a claim without a doctor's support.

Preferred Types of Treatment Providers

SSA considers certain treatment providers as "acceptable medical sources." These include:

  • licensed physicians or psychiatrists
  • advanced practice nurses and advanced registered nurse practitioners
  • physicians assistants (PAs)
  • licensed optometrists
  • licensed podiatrists
  • licensed audiologists
  • qualified speech-language pathologists, and
  • licensed or certified psychologists, including school psychologists.

Some of the above health care professionals only have the authority to interpret medical evidence within the scope of their license. For instance, Social Security will use an audiologist's opinion only for hearing and balance issues, and a school psychologist's opinion only for learning disorders, intellectual disorder, and borderline intellectual functioning.

Note that chiropractors are not on this list. Only an acceptable medical source can diagnose and provide evidence to establish that you have a "medically determinable impairment."

You can help your claim by submitting as much evidence as possible from these acceptable medical sources. Or, if you're relying on the SSA to gather the medical evidence, give them a complete list of all of your providers.

Hospital Records

SSA will also request information from any hospitals where you have been treated. If you're relying on the SSA to gather this medical information for you, be sure to provide a complete list of hospitals where you've been seen in the emergency room and/or admitted in the last five years, or even longer if your disability began long ago.

Types of Records to Submit

Your 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 the following:
    • 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.
    • Your 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.

Submitting 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 related to your symptoms that affect your ability to function, such as pain and fatigue.

The SSA will also take the following into consideration:

  • limitations on your daily activities
  • factors that trigger your symptoms to occur or make them worse
  • the effects 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.

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 Social Security, and is critical to your claim, evidence from other sources can help to explain the effects 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.

Social Security Consultative Exams

Don't 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. But 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 will have to see the 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 a physician who knows your medical history well can provide much stronger support for your disability claim than a doctor who spends one short visit with you.

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