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5 tips on how to document your medical condition for SSD

Written by Ankin Law Office

Many Social Security Disability claims are denied for medical reasons. In August 2014, the Social Security Administration reported that over 20 percent of all 2010 SSD claims were denied on this basis. Some medical conditions fail to meet the SSA’s strict standards. However, as any Social Security Chicago attorney knows, many claims are denied because of poor medical documentation. Applicants can reduce their risk of claim denial by using the following five tips when gathering medical evidence.

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Choose appropriate medical sources

The SSA considers various sources of evidence when evaluating whether a person is disabled. However, an “acceptable medical source” must diagnose the disabling condition and provide a professional medical opinion of the condition. The SSA recognizes physicians, podiatrists, optometrists, psychologists, psychiatrists and speech-language pathologists as acceptable sources, provided they carry relevant licenses or certifications.

In addition to seeking treatment from a professional who is considered an acceptable medical source, applicants should evaluate whether the professional is supportive. A doctor’s opinion carries significant weight in an SSD claim. If a doctor believes an individual is not legitimately disabled, or if the doctor is not willing to dedicate time to supporting the individual’s claim, approval for SSD benefits is unlikely. Applicants with unsupportive doctors may want to consider seeking medical attention elsewhere.

Long-term treatment from the same medical source can bolster an SSD claim. Therefore, applicants should focus on finding a suitable medical source as early as possible.

Establish regular treatment records

Regular visits to a treating medical professional can help an applicant establish a detailed and ongoing treatment record. This can help show the progression of the disabling condition. A solid treatment record can also increase an applicant’s credibility. Social Security Chicago applicants may appear dishonest if they state they suffer from long-term afflictions but lack supporting medical records.

To further build credibility, it is essential for SSD applicants to adhere to all prescribed treatments. This is the only way applicants can prove a condition is disabling. Without a full treatment record, the SSA may question whether a condition could be managed through medication, rehabilitation, counseling or other measures.

The SSA acknowledges a few valid reasons for failure to follow doctor-prescribed treatments. These include:

  • Inability to pay for the treatment
  • Religious beliefs that do not permit the treatment
  • Conflicting opinions from different medical sources about the necessity of the treatment
  • Mental illness or physical conditions that make following the treatment unreasonable
  • Extreme fear of surgery

Outside of these situations, however, the risk of claim denial can be high when applicants do not follow treatment protocols.

Show functional limitations

Depending on the condition, medical evidence alone may not prove an individual meets the SSA’s definition of disability. Individuals who suffer from conditions listed in the “Blue Book” of impairments and meet relevant criteria may receive benefits based on medical diagnoses, tests and records. However, other applicants must supply evidence to prove the disabling condition causes significant functional limitations.

A Residual Functional Capacity form, which a treating physician completes, can help illustrate the specific effects of a disabling condition. The RFC form supports a detailed analysis of physical or mental limitations associated with the disability. For instance, when filling out the form, a physician can note how long an applicant can stand without a break, or how efficiently the applicant can perform fine motor tasks.

If an applicant does not qualify for benefits based on a Blue Book listing, the SSA conducts its own RFC assessment to decide whether the applicant should receive a medical-vocational allowance. Applicants benefit from asking a treating physician to complete an RFC form in advance. A treating physician can usually analyze RFC more accurately than a physician who has not met the applicant.

Supply medical documentation

SSD applicants should provide the SSA with as much medical evidence as possible. SSA disability examiners are responsible for securing all of the medical records relevant to an applicant’s claim. However, it is possible for examiners to overlook important records. Additionally, hospitals, doctor’s offices and other care facilities are sometimes slow to provide records. This can lead to delays or claim decisions based on incomplete medical records.

SSD applicants can request copies of their medical records from treating sources and care facilities. Although applicants do not need to provide a full medical history, they should include any documentation that may be relevant to the claim. This generally consists of medical and treatment records, along with objective evidence, such as the results of lab and clinical tests. Applicants should also include objective evidence from non-acceptable medical sources. The SSA recognizes this evidence as valid.

People seeking SSD benefits should submit their medical documentation along with their applications. Applicants also may want to provide contact information for all treating medical sources and facilities. This ensures the SSA disability examiner can follow up with the original sources for any additional information needed.

Use supporting sources

Finally, SSD applicants should supply documentation from non-medical sources to support their Social Security Chicago disability claims. Friends, co-workers, family members and other people who have personal relationships with the applicant may attest to symptoms and other effects associated with the condition. This evidence serves primarily to show how the disability affects the applicant’s work and daily life.

The SSA considers information from non-medical sources, but this information carries less weight than objective medical evidence. Therefore, applicants should focus first on acquiring medical evidence that meets the SSA’s strict standards. Then, applicants can secure additional evidence from other sources to strengthen the claim.

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