When applying for disability benefits through the Social Security Administration (SSA), you will need to present evidence showing that you have been unable to work for at least a 12-month period. You can help satisfy this burden by having your primary care doctor complete what Social Security calls a "medical source statement." (A medical source is a doctor, clinic, or other healthcare provider.)
Here's what the doctor should include in a good medical source statement.
(If your doctor is less than helpful, please see this page.)
As part of the SSA's requirements for Social Security disability insurance (SSDI) benefits or Supplemental Security Income (SSI), you must be diagnosed with a medical condition ("impairment") by a licensed doctor or psychologist. In addition, to be evaluated for disability, this impairment must have more than a slight effect on your ability to perform work.
If your medical records are not that lengthy or comprehensive, by submitting a medical source statement to Social Security, your doctor can show exactly what medical conditions you have been diagnosed with. Moreover, the doctor can explain what symptoms and limitations you are experiencing from your impairments. The failure of the SSA to properly consider all of your impairments can be a strong basis for any future disability appeal, so it is good to have them all documented in your claim file.
You should ask your doctor or psychologist to comment on whether your medical conditions meet or "equal" the requirements of a disability "listing" that's relevant to your impairment(s). For instance, if you have poor hearing, you might meet Social Security's listing for "hearing loss." Social Security's disability listings are found in its Blue Book. Most doctors will need to be given a copy of the particular disability listing for reference.
Even if you suffer from many serious health conditions, the SSA likely will discard a letter from your doctor that simply states you are "disabled" or "cannot work." This is because the role of determining disability lies solely with the SSA.
Instead, you should have your doctor discuss how long you can perform exertional activities such as standing, walking, and sitting in an eight-hour workday. Another important strength requirement is the amount of weight you can carry and lift during the day.
The SSA will use your exertional capabilities and limitations, as reported by your doctor, to determine your "residual functional capacity" (RFC), as part of its five-step disability determination. Your RFC is your ability to perform various work tasks on a regular basis.
Your RFC will also be based on nonexertional activities, activities that don't involve strength. Your doctor should include in your medical source statement whether you have limitations in any of the following areas.
When your doctor provides limitations of your RFC, then the doctor should explain how he reached the conclusion that you are limited in these areas. For instance, if you cannot stoop or crouch due to a spinal fusion, your doctor should state that a previous spinal fusion prevents you from stopping and crouching, and why.
The SSA does not need you to be limited in all functional areas to approve you for disability. Any restriction in your RFC could potentially impact the SSA's findings during the last step of the disability evaluation process. At this final step, the SSA will take into account your age and education to determine whether your RFC prevents you from performing any jobs that exist in the U.S.
The SSA could find you disabled if you are unable to work on a regular basis for a 40-hour workweek. As such, your doctor should discuss whether fatigue or pain would cause you to miss any days of work in a typical month, and how many days of work you would miss. For example, your doctor could verify whether you experience ongoing flare-ups of pain from your back impairment, the pain cannot be effectively controlled by medication, and the level of pain is so severe that it prevents you from performing work activities for at least three days a month.
Your doctor should mention whether you have any side effects from your prescribed medications. If you have serious side effects, you could be unable to perform the mental demands of work and might have trouble completing tasks under deadlines.
The SSA will review your medical records to see if there is any inconsistency with the doctor's medical notes and his opinion of whether you are disabled. For instance, if the doctor opined that you were unable to stand for a majority of the workday, but all of his routine examinations of you were normal, then the SSA might reject the doctor's medical opinion. Generally, an opinion by a treating doctor (a doctor with whom you have had a longstanding relationship) will be given strong weight by the SSA if the opinion is supported by the medical evidence in the doctor's records and other medical records.
If you have questions regarding how to obtain a medical source statement or what should be in it, you should consult with a disability attorney.