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 doctors you have given them, it is your responsibility to ensure that the agency has received all of your relevant medical records, and that your disability 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.
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.
The exact information you need to get from your doctor(s) depends on the basis of your disability claim. Here are some examples.
Back pain. A claimant (applicant) 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:
Mental illness. A claimant who files for disability based on bipolar disorder and generalized anxiety disorder and who has attended an in-treatment program at a local psychiatric facility needs the following type of information:
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:
Remember that many of these pieces of evidence are in addition to the relevant medical records that your doctors should submit to the SSA.
The Social Security Administration 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.
A claimant was diagnosed with skin cancer, specifically sarcoma. Sarcoma of the skin is eligible for automatic approval for benefits under the disability listing for skin cancer, 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 made sure that the SSA had the following information from her doctor:
To find out if your condition might meet a listing, and what your doctor needs to provide to prove you meet the criteria of the listing, visit our section on disability listings for more information.
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 intensive work you can do on a regular and sustained basis. RFCs can be either physical or mental assessments.
Your claims examiner and a medical consultant who works for the SSA will create an RFC for you using the objective medical evidence in your file. But it helps if your doctor also submits an RFC form for you. 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 doctors' 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:
You can download a physical RFC form from our website to give to your doctor to complete, or if you have an attorney or disability advocate, they will provide one to your doctor. To learn more about how your doctor can help determine your physical RFC, see our article on getting your doctor to fill out an RFC form.
Here are some things that a mental RFC should discuss:
Statement about reliability and attendance. 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.
Special physician's statement about drug and alcohol abuse. Your mental RFC should also contain answers to the following questions.
The reason your doctor must answer these questions 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.
Before your psychiatrist or other mental health professional completes the RFC form, you may wish to share with them your views on what you can do on a day-to-day basis. Sharing your honest opinion about your ability to interact with co-workers and bosses, maintain focus and concentration, and perform other work-related tasks will give your psychiatrist insight into the troubles you would face in the workplace.
Of course, your psychiatrist will have their own opinions on what you can and can't do, but many doctors find it helpful to hear their patients' self-described limitations.
Above all, be sure to obtain as much mental health treatment as you reasonably can, both for your own health and for the sake of your disability claim. The more you can explain to your psychiatrist the symptoms you're experiencing—whether panic attacks, suicidal thoughts, mania, hallucinations, or something else—the greater your chances of success in your disability case.
For more information on how your psychiatrist can help determine your RFC, see our article on mental RFCs.
Because the medical evidence and doctors' opinions you provide to the SSA in support of your claim will largely determine whether you win or lose your disability claim, you may want to contact a lawyer or advocate. Experienced disability attorneys and advocates are trained to identify what type of information you need to win and will look over your case to determine what further evidence you need.
Updated February 28, 2022