When evaluating your Social Security Disability claim, the Social Security Administration (SSA) will look at your medical records and doctor’s opinion to decide whether your condition truly inhibits your ability to work (substantial gainful activity) for at least 12 months. This is why it’s important to see your treating doctor on a regular basis to ensure your medical records are up to date and accurately reflect the number and severity of your symptoms.
But in addition to treatment notes, lab reports, x-rays, and imaging studies, one of the most compelling items the SSA’s Disability Determination Service (DDS) can evaluate is a medical source statement from your primary treating physician.
“A good medical source statement will outline what an individual is capable of performing when it comes to lifting, sitting, standing, and walking,” said Dr. Dale Robbins, M.D. J.D. “If you can have them list any postural and environmental limitations, that would be great as well.”
You can get a medical source statement form from the SSA, or your attorney can draft one for your specific impairment.
“You should approach your primary care provider or the appropriate specialist to fill out the doctor’s letter,” said Robbins. “If you’re suffering from depression and your primary care doctor is treating it, they should be the one to fill it out. But if you’re seeing a psychiatrist for your depression, then you would have your psychiatrist fill it out.”
You shouldn’t feel reluctant to ask for your doctor’s help with your Social Security Disability claim either. Your Social Security Disability approval will only benefit you and your doctor.
“If the patient gets approved for disability insurance or SSI, they will be able to afford ongoing medical care, so it’s better for both the patient and the doctor,” Robbins said.
If you approach your doctor and he or she seems hesitant to fill out the form for your disability application, you can offer to pay for their time. However, if they are still reluctant to help, you may have to move on to the next best choice: a medical professional who is treating you and is familiar with your condition but may not be the one providing primary treatment. Talk to a Social Security disability attorney if you need advice. If your claim lacks medical evidence, you will likely be required to have a consultative exam performed to get another doctor’s opinion.
“The SSA has something called the “treating physician rule,” which means that the treating physician is in the best position to know what is going on with a particular patient in terms of their conditions and care. The most important thing to know about the treating physicians rule is that they are just that – it must be an M.D., D.O., or Ph.D. A nurse practitioner or physician assistant does not qualify under this rule, but nonetheless, if that’s who you can get to fill out a medical source statement, by all means do so,” said Robbins.
If you have any questions about which medical professional(s) you should approach about filling out a medical source statement, consult with your attorney since they will be the most familiar with the SSA’s examination process. You can also contact your local Social Security office. When asking your doctor to fill out a medical source statement, Robbins recommends trying to get them to be as specific as possible, and to focus on the condition(s) that limit your ability to work.
“You don’t want the doctor to consider everything, because then it becomes overwhelming,” said Robbins.
At the end of the day, the biggest thing you can do to help your own case is to be absolutely honest. The SSA will have you complete a form about how you spend your day, and if that form and your medical records or medical source statement are inconsistent, it can be a big red flag and lead to a negative disability decision.
“What I tell my clients every time is to tell the truth. I can deal with the truth,” said Robbins. “It’s when you tell me something that’s not true and then there’s documentation elsewhere in the file that says otherwise, that’s when we have to backtrack.”
For SSDI benefits, what the SSA is looking for is whether your medical condition will keep you from performing substantial gainful activity (not to be confused with SSI, which is income-based). Your doctors can be your biggest advocates in showcasing how your disability interferes with your day-to-day life, and you should work closely with them to document your struggles and limitations. It may require some additional footwork on your part to make sure these limitations are properly documented, but in the end it will be worth the extra effort.
