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Medical Documentation and Your Social Security Benefits

Social Security benefits are designed to assist individuals who have medical issues that affect their ability to provide for themselves. Because benefits are awarded based on the effects of injuries and conditions, the Social Security Administration (SSA) requires medical documentation with each application.

The medical documentation you provide directly impacts your approval and duration of benefits. When you understand the relationship between medical documentation and Social Security benefits, you can ensure that you receive the aid you need to supplement or replace income, receive essential treatment, and maintain your quality of life.

In this blog, we answer some of the most common questions about medical documentation in the application process.

Which Standards Should Documentation Meet?

Each injury and condition covered under Social Security has different deciding standards that a claim must meet before an applicant can receive benefits. However, before the debilitating situation cited in your application is evaluated, your documentation must first be assessed. The SSA representative who evaluates your application will consider your medical documentation with the following criteria in mind:

  • Accuracy. The SSA requires as much objective medical evidence as possible. For example, opinions from physicians carry less weight than exam findings, test results and X-ray images.
  • Sufficiency. In order for an applicant to qualify for benefit, his or her condition must be considered both severe and long-term. Your medical documentation must include adequate evidence to support both criteria.
  • Timeliness. The SSA requires that you include medical documentation that reflects your current status, as well as your status on the date you say you became disabled.  

If your medical records do not meet these standards, you will be more likely to receive a medical denial on your application.

What Types of Documentation Will You Need?

The types of medical documentation necessary to support your claim vary according to the injury or condition listed in your application. For example, you must include psychological assessments for any behavioral health-based application, and physical medicine records for your physical problems.  We urge you list every provider (or clinic if the providers are in the same clinic) you have seen for any reason.  We sometimes find that providers will comment on problems you are not seeing them for, or an x-ray of your chest may also show degenerative disk disease. 

Keep in mind as you collect documentation that the SSA has strict standards about what medical sources it considers authoritative. Standards have changed, but generally only objective records from healthcare providers like medical doctors, licensed psychologists, optometrists, APRN’s, physician assistants and osteopaths qualify as acceptable treating sources.

However, objective test and imaging results from healthcare providers that are not considered authoritative can be used. For example, if your most recent X-ray images were taken by a chiropractor, these images can be used as evidence, but the chiropractor’s notes cannot.

How Far Back Must Your Medical Record Extend?

You should document the case from the time you were first seen for any problem that is disabling.  However, as mentioned in the first section, you must also have recent documentation in order to submit an application. This medical documentation tends to carry the most weight.

When Must You Update Medical Documentation?

Many debilitating conditions can change quickly. If your condition changes, for better or worse, you are responsible for letting the SSA know. If you have not been assigned a claims manager when the change occurs, bring or mail your new documentation to the nearest SSA office.

If your application is in the consideration process or you have already received an approval, deliver your documentation to your claims examiner.

If the change occurs after you have been denied, you can include the new records with your appeal.

What Happens If You Don’t Have Enough Documentation?

While lack of medical evidence is one of the most common reasons for application denial, inadequate documentation is not necessarily the same as lack of evidence. If you do not have medical records that go back very far, current records, or documents that demonstrate your daily symptoms, your claims examiner may require consultative exams.

These exams give your claims examiner a clearer picture of the extent of your disability through medical tests pertaining to mobility, vision acuity, and so on.

To ensure that you have prepared your best possible application, meet with an experienced Social Security attorney. When you need assistance with your Social Security benefits application or appeal, trust the proven expertise of Glen Cook Social Security Attorney.