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A huge part of a social security disability case is the development of the medical record. The medical record is what forms the foundation of any disability claim for benefits. The reason for this is that any approved claim for disability must be supported by medical documentation of the alleged reason for disability. This means the medical record is very, very important to a claim. A claimant who alleges a particular medical impairment that has made them unable to work, must be able to show a medical basis for that alleged impairment. Of course, some people cannot afford the same level or amount of medical treatment as others, and that fact will not necessarily be held against the claimant if the issue is a financial one. A medical record is built partially by the social security administration and can be supplemented by an appointed rep and/or the claimants themselves.

  • Beginning the medical record foundation: When a disability claimant initially applies for social security disability, whether online or in person, the process will require that the claimant provide a signed medical release allowing the social security administration to request and obtain records from relevant medical providers. Usually, this is accomplished by including the claimant’s treating doctors in the application; then the social security administration will request medical records from the listed doctors using the signed medical release form provided by the claimant. This is the beginning of the development of the medical record. As time goes on, the social security administration may decide it needs to supplement records with other evaluations. I will discuss this further in the second part of this article. As the claim progresses through the process from application to reconsideration (if this step exists in the claimant’s state), and through to hearing, an appointed rep can keep track of any and all new medical treatment. But the social security administration will almost always begin the medical record collection process. It is very important to include all treating doctors, their treatment, dates, and contact information when initially applying or appealing a decision by social security.
  • Social security ordered Consultative Examinations: Occasionally the social security administration will order what is known as a consultative examination. This is an examination by a third-party doctor (a doctor who has not previously treated the claimant) in order to obtain a second opinion or an affirmation of the claimant’s alleged impairments. This is common when the claimant alleges certain physical or mental impairments that keep him or her from working, but the medical record is sparse regarding that particular impairment. The medical record may be lacking due to difficulties with finances, no insurance, or any other reason. A consultative examination may be physically based or mentally based. The social security administration will send the claimant a notice in the mail requesting the claimant attend said consultative exam on a particular date and with a particular doctor of their choosing. This appointment is very important to attend. No matter what, a claimant should always make it a point to attend the consultative exam.
  • Updating medical records: Particularly when set for a hearing in front of an administrative law judge, the claimant or appointed representative should keep track of any new medical treatment as time passes. The importance of having recent, updated, and relevant medical records at the hearing cannot be overestimated. Many times, if medical records are old or simply have not been updated for some time, the Administrative Law Judge may feel unable to verify the continuation of an alleged medical impairment, and this could negatively affect the outcome of the hearing. Further, your appointed rep can provide documents called medical source statements to you or your provider and request that they fill them out. This can be very helpful to your claim, as it is a directed series of explanations regarding what the claimant can and cannot do on a daily basis as a result of their alleged impairments. While not binding on a Judge’s decision, they can certainly be helpful.

Overall, the medical record development and updating can be the most important, and sometimes the most frustrating part of the process. An experienced attorney rep can typically make the process simpler and easier.