The Social Security Administration (SSA) relies on doctor's records and medical evidence to determine whether you are disabled. Although the SSA will request records from the list of providers you have given them, it is your responsibility to ensure that the agency has received all of your pertinent medical records, and that your doctor has provided the information in a helpful way. Submitting accurate and complete information from the doctor(s) who treats you for your impairment is vital to winning your claim.
Which Doctors’ Records Do I Need?
You need to provide medical records only from the doctors who have treated you for your disabling condition. If you have multiple disabilities, you will need to provide the SSA with medical records from all of the different doctors who have treated you.
Make sure that you don’t provide the SSA with irrelevant medical records. For example, if your claim is based solely on mental illness, you do not need to provide records from your allergist, eye doctor, or any other physicians who are unfamiliar with your mental condition.
What Information Do I Need to Get From My Doctor?
The exact information you need to get from your doctor(s) depends on the basis of your claim. Here are some examples.
Back pain. A claimant who files for disability based on lumbar and thoracic spinal stenosis and who has received treatment from an orthopedic doctor, a neurosurgeon, a physical therapist, and a pain management doctor needs the following types of information:
- copies of CT scans, x-rays, and MRIs that show the extent of the spinal stenosis
- radiologists' reports that describe the findings from imaging studies
- records from any surgical attempts to relieve the symptoms (for example, decompression surgery)
- detailed records of pain management visits, including medication list, dosages, reported side effects, and results from random urinalysis demonstrating compliance with prescribed medication
- detailed physical therapy plan and the applicant's response to treatment
- statements from doctor(s) about applicant's ability to work (discussed more below), and
- physical residual functional capacity (RFC) assessments (discussed more below).
Mental illness. A claimant who files for disability based on bi-polar disorder and generalized anxiety disorder and who has attended an in-treatment program at a local psychiatric facility on weekends needs the following type of information:
- a detailed medication list that included dosage amounts, reported side effects, and a doctor’s statement regarding compliance
- a psychiatric evaluation that formally diagnosed the claimant with bi-polar and generalized anxiety disorder using the Diagnostic and Statistical Manual of Mental Disorders
- a mental RFC prepared by both his psychiatrist and psychologist (discussed in more detail below)
- a statement from both his psychiatrist and psychologist that said drugs and alcohol are not a factor in his disease
- a statement from the mental health facility about claimant’s ability to interact with other patients and his involvement and compliance with the program, and
- a statement from a psychiatrist regarding whether the doctor believes the claimant satisfies the disability listing requirements for automatic approval, and detailing the basis for that belief (to be discussed in more detail below).
Combination of impairments. A claimant who files for disability based on type 2 diabetes, chronic obstructive pulmonary disease (COPD), and depression needs to provide the following types of information in support of her claim:
- a physical RFC (from a heart and lung doctor),
- a mental RFC (from a psychiatrist)
- a statement from both the doctor and the psychiatrist saying drugs and alcohol are not a factor in the claimant's depression
- a psychiatric evaluation that formally diagnosed the claimant with depression using the Diagnostic and Statistical Manual of Mental Disorders
- statements regarding the likelihood that the medical conditions will improve, and
- a detailed description of the claimant's medications and documented side effects.
Remember that these particular pieces of evidence are in addition to the relevant medical records you should submit to the SSA from these providers.
Whether You Meet a Disability Listing
The SSA outlines a number of conditions that, if all the criteria are met, are eligible for automatic approval. These conditions are known as “listings.” If your doctor thinks that your condition qualifies for automatic approval under a listing, the doctor should complete a listing form that explains his or her opinion and provide the appropriate medical documentation. Here is an example.
The claimant was diagnosed with skin cancer, specifically sarcoma. Sarcoma of the skin is eligible for automatic approval for benefits under the disability listing for cancers if the cancer has spread (metastasized) to, or beyond, the regional lymph nodes. A biopsy revealed that the claimant's cancer had spread. To prove she met the listing requirements for sarcoma of the skin, the claimant provided the following information from her doctor.
- The pathology report that initially diagnosed the claimant with sarcoma of the skin.
- A surgical and pathology report that established that the sarcoma cells had spread to her lymph nodes.
Visit our section on disability listings for more information.
Providing Your Residual Functional Capacity (RFC)
An RFC (which stands for residual functional capacity) is a detailed assessment of your ability to perform certain work-related activities in light of your symptoms. Your RFC is the most you can do on a regular and sustained basis and is created using the objective medical evidence in your file. RFCs can be either physical or mental assessments. If your condition doesn’t meet a listing, then RFCs are one of the most important things that your doctors can provide for you.
Remember, though, that RFCs must be supported by objective medical evidence for the SSA to give them consideration; otherwise the SSA can disregard them.
Here are some examples of the things that a physical RFC should discuss:
- how much you can lift and how often
- how much you can carry and how often
- how long you can sit down (uninterrupted)
- how long you can stand (uninterrupted)
- how far you can walk
- any environmental restrictions (such as sensitivity to dust or temperature)
- any postural restrictions (such as inability to stoop, bend, kneel, or reach overhead), and
- sensory limitations (vision or hearing difficulties).
You can download RFC forms from our website to give to your doctor to complete, or if you have an attorney, he or she will provide one to your doctor.
Here are some things that a mental RFC should discuss:
your ability to understand, remember, and carry out simple instructions
- your ability to interact with co-workers
- your ability to react to criticism or authority figures
- your ability to interact with the general public
- your memory
- whether your condition is likely to cause a disruption in the workplace
- whether you can maintain appropriate dress and hygiene
- whether you are reliable, and
- how your condition affects your ability to concentrate, focus, and complete tasks in a normal amount of time.
For more information, see our article on mental RFCs.
Special physician’s statement about drug and alcohol abuse. Your mental RFC should also contain the following questions, and your doctor must answer them.
- Does the claimant use illicit drugs or abuse prescription drugs or alcohol?
- If the claimant does use illicit drugs or abuse prescription drugs or alcohol, would the claimant's impairment still exist in the absence of the abuse?
The reason these questions must be answered is because if you abuse drugs or alcohol and your condition would go away if you quit using, the SSA will most likely deny your claim.
Statement about reliability. RFCs from your doctor should also contain a statement about how your illness is likely to affect your reliability and ability to attend work regularly, due to issues such as fatigue, pain, ongoing treatments, or frequent hospitalizations.
Contact an Attorney for Help
Because the medical evidence and doctors' opinions you provide to the SSA in support of your claim will be determinative in whether you win or lose your disability claim, you may want to contact a lawyer. An experienced disability attorney is trained to identify what type of information you need to win and will look over your case to determine what further evidence you need. Consult an experienced disability attorney in your area.