Your Guide to Medical Records for Disability Hearings
According to the Social Security Administration (SSA), under both the title II and title XVI programs, medical evidence is the critical factor that determines disability.
Each person filing a disability claim must provide medical proof of their disability and the extent of the disability. However, with the claimant’s consent, the SSA will obtain medical evidence from medical providers who treated the claimant.
When necessary, SSA also obtains copies of medical evidence from health facilities.
Claimants who give the SSA correct information and documentation on time can have their claims processed more quickly, and a social security disability lawyer can help expedite the process.
To prove a claimant’s disability, the Social Security Administration (SSA) requires thorough medical documentation. SSA regulations demand “objective medical proof” from an “acceptable medical source,” defined in their rules.
The SSA weighs every piece of medical and non-medical evidence after establishing an impairment to determine its impact on the claimant’s ability to work. For children, it’s about the functionality of their peers with no impairments. Everyone from home to work, the community, and religious organizations can be non-medical sources.
Claimants must inform SSA of all evidence relating to their disability or submit it to SSA. This obligation is ongoing, for further proof that comes to light during the administrative review procedure and should be complete and precise enough for the Social Security Administration to determine:
- The nature and extent of the claimant’s disability (s),
- How long has the claimant had the impairment(s)
- Can they continue to perform mental and physical activities at work while suffering from them
Exams for Consultation
If the claimant’s data is insufficient to decide whether they’re incapacitated, the SSA might arrange a consultation examination (CE) for clarification. In most cases, a claimant’s medical source(s) is recommended for performing the required exams, and SSA will cover the permitted charge for the CE. SSA sometimes utilize independent medical source if:
- The claimant’s physician declined
- The claimant’s medical source(s) lacks the equipment necessary to give the exact data required
- There are disputes or discrepancies in the file that cannot be resolved by returning to the claimant’s medical source
- The claimant prefers and has reasonable justification for using another source
- Because of previous experience, SSA understands that the claimant’s medical source(s) may not be a productive source
- The claimant’s medical source(s) is not qualified, as defined by regulation, which social security disability lawyers can help you to correct.
Content of the Consultative Examination Report
The CE report should include all the examinations in total, which should contain the following:
- Principal or primary grievance(s) of the claimant
- A thorough explanation of the history of the principal complaint(s) within the scope of the examination.
- A detailed description of lab, history, exam, complaints, and any other abnormalities or lack thereof reported or found during analysis or laboratory testing; results of laboratory and other tests (for example, X-rays) performed according to the requirements stated in the Impairments Listing
- The claimant’s impairment(s) diagnosis and prognosis.
A statement regarding what a claimant can perform and their limitations in the following abilities in adult claims:
- Handling physical tasks at work.
- Understanding; remembering; sustaining focus, tenacity, or pace; carrying out instructions; or responding effectively to supervisors, coworkers, or work pressures in a work situation.
- Ability to meet other job requirements, such as seeing, hearing, or using other senses; and
- Being able to adjust to changing conditions in the environment, such as temperature extremes or pollutants.
A statement about the child’s limitations and restrictions compared to peers without impairment:
- In acquiring and using information
- Attending to and completing tasks
- Interacting and relating with others
- Moving around and manipulating objects
The evidence presented by the consultant who signs the report will represent the history, examination, interpretation of laboratory test findings, and conclusions.
SSA considers all options related to the complaints when creating proof of the consequences of symptoms such as pain, shortness of breath, or weariness on a claimant’s capacity to function.
The evidence includes information on the claimant’s daily activities, ailments, accelerating and aggravating factors, medications; any measures the claimant uses or has used to relieve pain or other symptoms; and other factors. A social security disability attorney can help you get the correct information.
The SSA analyzes all these variables when evaluating the claimant’s pain or other symptoms. The medical source must mention these issues in their findings.
How an SS Disability Lawyer can Help
It can be challenging to ensure that the Social Security Administration gets all it requires, but a Baltimore SS disability lawyer from the Law Offices of Terri D. Mason can assist you. Social security disability attorneys can liaise between the SSA and your medical providers, resolving communications and medical evidence submission delays.