When you apply for either SSI or SSDI, you will need to provide medical evidence of your disability to the Social Security Administration (SSA). The SSA will examine this evidence to decide whether or not you qualify as disabled under the SSA’s definition. In order to make sure your application is processed and the SSA makes a decision as quickly as possible, the proper evidence of your impairment should be in your medical records before you apply. You do not have to provide your medical records yourself to the SSA, if you don't want to. Instead, with your permission, the SSA will help you get your records sent to the SSA. (However, submitting the records to the SSA yourself can speed up the decision-making process.)
What Is an “Acceptable Medical Source”?
Once the SSA determines you have an impairment, they will look at all medical and non-medical evidence to determine how severe the impairment is. The SSA will look at records and documentation only from “acceptable medical sources.” The following are acceptable medical sources.
- Licensed physicians or osteopaths who have an M.D. degree or a D.O degree. This does not include chiropractic, naturopathic, and other alternative providers.
- Licensed or certified psychologists. This includes school psychologists and people in similar jobs who are licensed or certified. However, psychologists are considered acceptable medical sources only for purposes of establishing mental retardation, learning disabilities, and borderline intellectual functioning.
- Licensed optometrists who have an O.D. degree. These are considered acceptable medical sources only for purposes of establishing visual impairments (either poor visual measurements or eye illness of any type).
- Licensed podiatrists who have a D.P.M. degree. These are considered acceptable medical sources only for purposes of establishing impairments of the foot, or foot and the ankle, depending on the state in which the podiatrist is licensed.
- Certain qualified speech-language pathologists. These are considered acceptable medical sources only for purposes of establishing speech or language impairments.
Evidence From Treating Sources
The most persuasive evidence often comes from treating sources that are also acceptable medical sources. The SSA gives more weight to evidence from these medical professionals because they are often the people who have been treating you over longer periods of time. For example, the SSA will take into account reports from an emergency room visit, but reports from a treating doctor (who is also an acceptable medical source) that you have been seeing for an extended period of time will get special attention.
The SSA recommends that in order to make sure there is sufficient evidence to make a disability determination, you should check that your medical records from your treating sources are “timely, accurate, and adequate.” If the reports in your medical records have those three characteristics, it is less likely the SSA will need to obtain additional medical evidence.
In order for your records to be “timely,” they should be fairly recent. How recent depends on what kind of impairment you have. If you have an impairment that does not change much from year to year, your records probably do not have to be as recent as if your impairment is one that progresses or changes very quickly.
Your medical records also should be accurate. Remember that in order to determine if you have an impairment, the SSA will look at information only from acceptable medical sources. For example, if your naturopath has records stating that you suffer from chronic anemia, but blood tests from acceptable medical sources do not validate that finding, the naturopath’s report will not be considered accurate.
Lastly, your records should be adequate. They should provide enough detail and evidence from acceptable medical sources to allow the SSA to make a decision about your impairment. For example, a diagnosis of chronic anemia is not sufficient. Your records should also show evidence such as blood counts and details on blood transfusions you have had.
Treating Source Statements
A treating source statement is a medical opinion that your regular treating doctor writes as to your ability to function with your impairment. The SSA must take this statement into account when this statement is supported by evidence. If you have a good relationship with your treating doctor (and don't think your treating doctor believes you can function better than you actually can), you should considering ask your treating doctor to include a statement, or perhaps a residual functional capacity (RFC) assessment in your records. Your doctor's statement should address how your condition affects your "activities of daily living" and your ability to perform work activities.
What Should Be in Your Medical Records
The SSA may want to see different kinds of specific evidence depending on your impairment, but in general, your medical records should include:
- medical history
- laboratory and clinical results
- a diagnosis from an acceptable medical source (who is also preferably your treating source)
- any treatment your doctor prescribed and how you responded to that treatment, and
- a treating source statement describing, based on medical evidence, the doctor’s opinion on how your impairment limits your ability to function.
Inadequate Records and Consultative Examinations
There are many reasons you may not have adequate medical records for the SSA to make a decision about your disability. The SSA understands that not everyone has the resources to regularly see a medical professional. If your records are inadequate, the SSA might ask your treating doctor to perform a consultative examination (CE). If your doctor does not want to perform the CE, or if you do not want your doctor to perform the CE, or if the SSA does not feel your doctor would conduct a proper CE, the SSA will arrange a CE with an independent doctor. The SSA pays for all CEs, even if your treating doctor is the one who performs the CE. Learn more about consultative examinations.