When you apply for disability benefits through the Social Security Administration (SSA), you'll need to present evidence that shows you've been unable to work for at least 12 months for Social Security to consider you legally disabled. This is where information from your doctors can be extremely helpful. Have your doctors and any other healthcare providers involved in treating your disabling conditions complete what Social Security calls a "medical source statement."
Here's what your doctor (or other healthcare providers) should include in an effective medical source statement.
As part of the SSA's requirements for Social Security disability insurance (SSDI) benefits or Supplemental Security Income (SSI), you must have a medical condition ("impairment") that has a significant effect on your ability to perform work. And you must be diagnosed with the impairment by a licensed doctor or psychologist.
If your medical records aren't very lengthy or comprehensive, your doctor can show precisely what medical conditions you've been diagnosed with by submitting a medical source statement to Social Security. And your doctor can explain the symptoms and limitations that your impairments cause.
If the SSA fails to properly consider all your impairments, it can be a solid basis for any future disability appeal. Because most claims are won on appeal, you'll want to have all your impairments and limitations documented in your claim file.
You might be automatically considered disabled if your impairment matches the requirements for one of the medical conditions listed in the SSA's Blue Book. You should ask your doctor or psychologist to comment on whether your medical conditions meet or "equal" a disability "listing."
For instance, if you have poor hearing, you might meet Social Security's listing for "hearing loss." Or you might qualify as disabled if you have a heart problem that meets the SSA listing. You'll probably need to give your doctor a link to the disability listings 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're "disabled" or "can't work." This is because only the SSA can determine if your condition qualifies you as disabled.
Instead, your doctor's statement should detail the medical evidence and the doctor's observations that show you're impaired. So, your doctor should discuss how long you can perform exertional activities like standing, walking, and sitting in an eight-hour workday. Your doctor should include important strength requirements like 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 process. Your RFC is your ability to perform various work tasks on a regular basis.
Nonexertional activities—those that don't involve strength—will also affect your RFC. Your doctor should include in your medical source statement whether you have limitations in any of the following areas:
When your medical source statement includes limitations for your RFC, your doctor should explain how those conclusions were reached. For instance, if you can't stoop or crouch due to a spinal fusion, your doctor should state that a previous spinal fusion prevents you from stooping and crouching and why.
You don't need to have limitations in all functional areas for the SSA to approve your disability claim. Any restriction in your RFC could potentially have an impact on whether the SSA finds you disabled during the last step of the disability evaluation process. At this final step, the SSA will consider your age and education to determine whether your RFC prevents you from performing any jobs that exist in the U.S.
The SSA can find you disabled if you can't work on a regular basis for a 40-hour workweek. As such, your doctor should discuss whether fatigue (extreme tiredness) or pain would cause you to miss any days of work. Your doctor should include how many days of work you would miss in a typical month.
For example, your doctor could explain that:
Your doctor should mention whether you have any side effects from your prescribed medications that could affect your ability to work. If you have serious side effects, for instance, you might be unable to perform the mental demands of work and might have trouble completing tasks under deadlines. Medication side effects could also make you sleepy or affect your coordination or reaction time.
The SSA will review your medical records to see if there are any inconsistencies with the doctor's medical notes and opinion of your limitations. For instance, if the doctor stated that you're unable to stand for most of the workday, but all of your routine examinations were normal, then the SSA might reject the doctor's medical opinion.
Generally, an opinion by a treating doctor (a doctor with whom you've had a longstanding relationship) will be given a lot of weight by the SSA—but only if the evidence in your medical records supports the doctor's opinion.
If you have questions about how to obtain a medical source statement or what should be in it, you should consult with a disability attorney.
(Get tips on filing for disability when your doctor is less than helpful.)