This is one of the questions that applicants have when they file a claim for social security disability. While it can be a little more complicated, the short answer is that medical documentation is very important to a claim for disability. The reasons for this are clear: social security rules require a claimant’s allegation of disability to be corroborated or backed up by medical records of some kind. In other words, it is simply not enough for a claimant to allege disability without medical documentation that shows the bases for disability exists according to a physician.
For instance, if a claimant is alleging that he or she became unable to work due to a serious back injury that resulted in pain, numbness, tingling, and inability to sit stand or walk for any appreciable amount of time, the medical record will need to establish that these allegations are in line with the diagnosis of a medical professional. If it’s not, the social security administration will deny the claim based on the fact that it is unsupported by medical records. So, if a claimant alleges that their back hurts constantly and the pain precludes full-time work, the medical records produced will need to show that there is a back injury that could cause these symptoms. If a claimant merely alleges a disabling condition without any medical evidence to back it up, the claim will be denied. This is one of the reasons that medical treatment is so very important to an SSD case.
Sometimes, a person claiming disability will have very few medical records to show, due to financial restrictions or lack of insurance. In some situations, social security will send a claimant to what is called a “consultative examination.” This is when the social security administration decides to send the claimant to a doctor of their choice for an examination that they pay for. If a consultative exam is ordered, it is extremely important for the claimant to attend this appointment. Social security will send a letter to the claimant, explaining where to go, when to be there, and what doctor they are to see. This doctor will typically perform an examination, speak to the claimant about their alleged disabling conditions, and write a report to the social security administration. This consultative exam can be performed for physical conditions as well as mental conditions. Sometimes a consultative examination will be related to allegations of mental disorders that have caused the disability and inability to work. In this situation the doctor will be a psychiatrist or psychologist, and the exam will be performed in a way that is more suited to a mental health disorder.
Medical records from treating doctors are always a very important aspect of a social security disability claim, and sometimes the more records there are the better the odds at achieving a favorable decision on a claim. For this reason, any person claiming social security disability should do everything in his or her power to attend all doctors’ appointments and to obtain any and all treatment possible. Of course, there are certain situations where a claimant is simply incapable of obtaining sufficient treatment due to inability to pay. In these situations, it is always advisable to seek out free clinics or indigent care through medical student treatment centers or through other charitable organizations. A certain kind of record, called a treating source statement, can be incredibly valuable to a disability claim as well. This is essentially a form filled out by a treating doctor, explaining what the claimant can and cannot do on a daily basis according to the opinion of the doctor. Some doctors will fill these out and some will not – but it’s always worth asking.
An experienced attorney rep will be able to provide a claimant with the proper form and make sure it’s uploaded to the SSA file ahead of the decision making process.