How to Gather Medical Evidence to Support Your Disability Claim
So, you've filed your application (or are filling it out now) for Social Security disability benefits. In order to get approved, you're going to need convincing medical evidence that proves you're unable to work. But gathering copies of your complete medical records can be costly, time-consuming and counterproductive. Learn which doctors you need to talk to and what records the Social Security Administration looks for below.
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Figure Out Which Doctors Are Acceptable Medical Sources for Your Disability Evaluation
The SSA keeps a list of acceptable medical sources who can provide evidence they'll consider when reviewing your disability claim. Who you need to pull records from depends entirely on which condition(s) you list on your benefits application.
If a physical impairment stops you from working, gather treatment records from these acceptable medical sources:
- Licensed doctors (medical or osteopathic physicians)
- Qualified speech-language pathologists (SLPs) with a state-issued license or Certificate of Clinical Competence from the American Speech-Language-Hearing Association
- Licensed podiatrists
- Advanced practice registered nurses (APRN, APN, CNS), certified nurse midwives (CNM), certified registered nurse anesthetists (CRNA) and nurse practitioners (ARNP, NP)
- Licensed optometrists
- Physician assistants licensed to assess impairments within the scope of practice only
- Licensed audiologists
If a mental health issue stops you from working, gather treatment records from these acceptable medical sources:
- Licensed or certified psychologists treating you through an independent practice
- School psychologists and other licensed or certified individuals that perform evaluations for intellectual and learning disabilities in educational settings
- Licensed podiatrists
Anyone who treats you that doesn't fit these descriptions can still provide supporting evidence for your claim. However, the SSA won't consider those sources until after they've reviewed your records from AMS providers first.
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Know Which Medical Records Matter Most for Proving Your Case
The SSA (or your state's Disability Determination Services office) must first review all objective medical evidence that supports your claim. Examples of objective medical records that help prove you're unable to work may include:
- X-rays, CT scans or MRI results
- Assessment records from when you got your wheelchair, cane, hearing aid(s), mobility scooter, crutches or other medical devices required for daily living
- A Physical or Mental Residual Functional Capacity (RFC) form your doctor signed and completed within the last 90 days
- Your doctor's treatment notes and complete medical records relating to your disabling condition(s)
- Laboratory test results from the last 12 months
- Hospital admission dates and release records (including any relevant ER visits)
- Outpatient surgical procedures related to your impairment (i.e., limb amputations, pacemaker, insulin pump insertion/removal, etc.)
- IQ and/or neuropsychological tests as well as psychiatric evaluation results, if applicable
In addition to these records, make a complete list of all prescription and over-the-counter drugs you currently take. You can ask your pharmacist to print this list out for you, since it includes dosage, frequency, generic/name brand, etc. Once you have that list, write down any side effects and whether you're taking these medications exactly as directed.
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If You Can't Afford to Purchase Complete Medical Records, Talk to an Attorney
Many people mistakenly believe free records, such as mailed doctor's or hospital bills, are enough to prove their case. However, these documents don't contain vital information about your disability, like your doctor's treatment progression notes or clinical assessments. In every case, no matter what your impairment(s), you must pay for complete medical records to submit with your claim. It's not possible to prove your case qualifies for monthly disability benefits without them.
Once you've completed steps 1 and 2 above, we recommend doing this next:
- Call the doctor(s) you need records from and ask how much they'll charge to make copies. If it's more money than you can afford to spend, ask them to mail you a cost estimate. You typically only need a year's worth of records relating to your SSD claim, so don't pay for older documents!
- Schedule a free, no-obligation consultation with a nearby attorney to discuss your claim. When you arrive, explain that you can't afford to buy complete medical records to support your claim. Ask if the lawyer can get those records for you and include that cost in your contingency fee. That way, you have all the medical evidence you need as well as professional legal assistance filing your SSD claim.
The good news is, having an attorney pull and pay for medical evidence costs you nothing up front. Plus, having a lawyer file your disability claim makes you 3x more likely to get approved for benefits right away! Haven't seen a doctor in at least one year because you can't afford the visit? An attorney can pay for that so you have recent treatment records as well as medical evidence supporting your claim.
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Gather Other Non-Medical Evidence That May Help Support Your Claim
Depending on your impairment(s), you may wish to submit additional records that help support your case. These items aren't considered medical evidence, but they can show how severe your impairment is during your disability evaluation. Some examples might include:
- Letters and/or treatment records from non-AMS healthcare providers, such as naturopaths, chiropractors, acupuncturists, psychiatrists, therapists, etc.
- Files or records from your state's vocational rehab program (within the last six months).
- Letters from your at-home nurse, caregiver, or non-profit volunteer you interact with regularly (i.e., Meals on Wheels or paratransit bus drivers).
- Functional assessment records or notes from your assigned caseworker/social worker.
- Records showing which disability accommodations you need at school/inside your home.
- Letters from your family, spouse, neighbors, etc. explaining how your condition limits your ability to function every day.
Important: These items can help support your case, but they aren't enough to prove you qualify for disability benefits. Only objective medical evidence from all AMS providers treating your condition in the last year can prove your SSD claim.