Seeking a SSD medical evaluation

If you are a medical provider whose patient is applying for social security disability benefits, you may think a letter of medical condition from you is enough for their SSD application to be approved. Unfortunately, eligibility for benefits requires more than simply a doctor’s note stating that the applicant is disabled. Ensuring that you have the correct medical documents can become easier with a social security disability evaluation checklist.

Eligibility for SSD benefits requires not only the existence of a disabling condition expected to last more than 12 months or result in your patient’s death; the disabling condition must also make them unable to engage in substantial gainful activity. The more detailed the information you provide regarding your patient’s medical condition and its impact on his ability to work, the greater the chance that his SSD application will be approved.

To help, we’ve created this SSD evaluation checklist to ensure that the next time a patient asks for medical information in support of his SSD benefits application, you’ll know exactly what to provide.

Medical Source Statement. The medical source statement is the most vital document you can provide your patient to support his disability and its impact on his ability to work – yet is also the least likely document medical providers turn over. The Social Security Administration blue book contains more than 100 disabling conditions that qualify for SSD benefits, each with its own specific criteria. The medical source statement elicits information that is vital to helping your patient prove that the disability prevents him from being gainfully employed, but which usually is omitted from standard medical records.

A medical source statement that includes a detailed statement of your patient’s diagnosis, treatment, functional abilities (what tasks he can perform), and functional deficits (what tasks he cannot perform), provides a clearer picture of the negative impact that your patient’s disability has on his ability to work. Our office can provide you with the appropriate medical source statement for your patient’s particular disability.

Laboratory and diagnostic reports. All disability claims must be supported by objective medical evidence. Make sure that you provide the results of any and all laboratory or other diagnostic testing, such as blood work, MRIs, X-rays, CT scans and other diagnostic tests. If the SSA requires specific medical testing for your patient’s disabling condition, it is important that you perform those tests on your patient; failure to do so can result in their application being denied.

Medical notes. Your medical notes can provide a wealth of information detailing your patient’s disability, especially if they’re written correctly. The SSA issued new rules in 2017 that now allow them to give the same weight to medical evidence provided by the applicant’s treating physician as it does to its own medical examiners, who may evaluate your patient only once, if at all. So, it is more important than ever to give clear, objective information regarding your patient’s disability and its limiting effects on his functional abilities.

You can do this by using numbers to describe your patient’s condition. For example, instead of saying, “Patient’s pain prohibits him from sitting for extended periods” leaves too much open to interpretation. However, writing, “Pain associated with the patient’s condition makes him unable to sit for more than 10 minutes at a time without having to shift positions, and he can sit for no longer than 60 – 90 minutes 7 out of 7 days without needing to lie down for 10-15 minutes to alleviate pain.” is more helpful for your case.

Treatment notes. Notes regarding your patient’s treatment should list the type(s), duration, and results of each course of treatment, current and past, including the reasons why a treatment was discontinued.

Medications taken. A list of current and past medications you have prescribed to treat your patient’s condition, whether prescription or over-the-counter medication, should include dosage, frequency, duration, and reasons why any were discontinued or ended early.  

If you have any questions regarding the information you should provide in support of your patient’s SSD application, do not hesitate to call our office at #866-352-5238. We would be more than happy to answer any questions.

If you are seeking SSD benefits and are thinking of applying or have applied and been denied consider the Good Law Group for your representation.