What Medical Evidence Is Required by Social Security Disability?

Social Security disability needs timely, accurate, and sufficient medical evidence. Here's what that means.

By , M.D. | Updated by Nicole Moberg, Attorney

For a Social Security disability (or SSI) case, medical evidence takes many forms, including physical examination and treatment notes, mental health records, bloodwork panels, and reports of imaging studies (MRI, CT scan, and X-rays). The Social Security Administration (SSA) relies heavily on medical evidence to determine whether you're disabled.

Having timely, accurate, and sufficient medical records from your treating doctors (the doctors you see regularly) can eliminate the need for Social Security to obtain additional medical evidence, which means you can get a faster determination on your disability claim.

What's the Best Type of Evidence to Give to Social Security?

Social Security wants to see information in your medical records that's timely, accurate, and sufficient. Here's what this means.

Timely Records

Timely records are recent enough to be relevant to your current medical condition. How recent is a matter of medical judgment, depending on the disorder.

A condition that's rapidly changing requires more up-to-date information than one that is slowly progressive or unchanged for years. Generally, the SSA likes to have records no older than six months, though for some conditions, they may want to see doctor's treatment notes that are no older than three or four months. And some claims examiners or Social Security judges reviewing your file might be okay with medical evidence that's six months old, while others will want to see records that are less than three months old.

That doesn't mean older records aren't important. Records dating back many years may help provide the medical big picture (more on this below).

Accurate Records

Accurate records correctly describe your condition according to the standards of "acceptable medical sources". (Acceptable medical sources are medical doctors, osteopaths, physician assistants, nurse practitioners, and in some cases, licensed psychologists, audiologists, and optometrists.)

To use a common example, your chiropractor can describe subluxation (slippage) of your spine on X-rays, but Social Security won't consider this opinion as accurate if a medical doctor (M.D.) or other acceptable medical source reports that your X-rays are normal. (Social Security doesn't consider a chiropractor's records and notes as evidence of an impairment because chiropractors aren't medical doctors. But the X-rays taken by a chiropractor can be admissible as evidence.)

Also, if Social Security has objective evidence that conflicts with your doctor's medical opinion, the agency may not consider that opinion to be accurate. For instance, if your doctor's records say that you can't walk one block because of chest pain, but you've had specific exercise testing that shows that you can do much more exercise, Social Security is likely to reject your doctor's opinion.

Sufficient Medical Records

Sufficient medical records contain enough accurate information from acceptable medical sources to allow the SSA to make an independent medical judgment on how severe your medical condition is. For example, simply having a doctor's note with a diagnosis of cancer isn't sufficient. The SSA needs proof of your disability. The agency wants to know:

  • Did a biopsy prove the cancer's presence?
  • What is the exact type of cancer?
  • Where in the body is the cancer?
  • When did symptoms first appear?
  • What did a physical examination show?
  • What did X-rays and other imaging tests show?
  • What did blood tests show?
  • Did you have surgery?
  • Did the surgery remove all of the cancer?
  • Did you have chemotherapy?
  • What side effects did you suffer from the chemo, if any?
  • Did you have radiation therapy?
  • What were the results of the radiation therapy?

(Read more about the medical evidence required for disability based on cancer. Similarly, the evidence requirements for HIV-AIDS disability are specific and involved.)

What Other Medical Evidence Is Relevant for Disability?

Social Security needs to see specific evidence for your particular condition and how your condition limits your physical and mental abilities.

How to Find the Medical Evidence Required for Your Condition

Social Security keeps a list of conditions in what's known as the "Blue Book." The Blue Book lists about 100 conditions and the medical evidence that's required for each condition. If your medical records don't contain the test results required by a listing in the Blue Book, the SSA can't find that you meet that listing.

If you know your medical evidence is lacking, or you want help figuring out what medical evidence you need to prove your disability, read about how a disability attorney can develop the medical evidence that will best help your case.

Details About Your Symptoms and How They Affect Your Daily Activities

Social Security will also consider the effects of your symptoms and how they limit you, so your medical records should include evidence of:

  • your daily activities—what you can and can't do
  • the location, duration, frequency, and intensity of your pain or other symptoms
  • "precipitating factors" (things that cause or trigger symptoms)
  • "exacerbating factors" (things that make your symptoms worse)
  • the type of medication you're taking, including the dosage, whether or not the medication helps your symptoms, and whether you experience any side effects
  • anything else that you do to relieve pain or other symptoms, and
  • any other factors about your symptoms that limit your ability to function.

"Longitudinal" Medical Evidence

It isn't enough for your doctor to start keeping detailed records when you apply for disability. The SSA would like to see "longitudinal" records—that is, records that include your medical history over a number of months or years, especially if you hope to get retroactive disability benefits.

For example, say you were sick for six months before you applied for disability and were unable to work during that time. You could be eligible for a retroactive award of benefits for the six months you couldn't work. But if your doctor (or a past clinic or hospital you visited) doesn't have detailed medical records for the entire time period you were sick, you might not be able to prove you were unable to work during those six months.

How Far Back Does Social Security Look at Medical Records?

Social Security will generally consider all medical records for your disability claim that are relevant to the medical conditions you claim are disabling. The records should cover the entire period of time you've been disabled.

Specifically, the time period starts with your "alleged onset date" (AOD) and remains ongoing, unless the medical condition got better.

For example, if you tell Social Security that your onset date is January 1, 2022, you're telling Social Security that, as of January 1, 2022, you were no longer able to work—this is the "start date" of your disability, your AOD. To be found disabled back to the date of your AOD, you must have medical records going back that far. Even if that means the medical records are several years old, Social Security will review them.

(If your medical condition improved, see our article about impairments that get better before a hearing is conducted.)

Are There Types of Records That Aren't Helpful to My Claim?

The SSA can't evaluate medical records that are scribbled and unreadable, nor can they evaluate medical records that lack significant information about your condition.

Unfortunately, many records don't contain enough information for Social Security to determine disability. Here are some examples.

What Medical Records Are the Most Helpful to Disability Claims?

The best medical records for disability are those from your doctor that are typed, mention all of your complaints, show the results of examinations, note what treatment was given, state your response to treatment, and mention future plans and a prognosis.

The medical records that often carry the most weight with Social Security are "medical source statements" from your treating physician. Your treating physician will generally know your medical condition better than any other source. RFC forms are an ideal way for your doctor to let the SSA know what your symptoms and limitations are.

Updated March 23, 2023

Talk to a Disability Lawyer

Need a lawyer? Start here.

How it Works

  1. Briefly tell us about your case
  2. Provide your contact information
  3. Choose attorneys to contact you
Boost Your Chance of Being Approved

Get the Compensation You Deserve

Our experts have helped thousands like you get cash benefits.

How It Works

  1. Briefly tell us about your case
  2. Provide your contact information
  3. Choose attorneys to contact you