Qualifying medical evidence is the most important part of proving that a Social Security case is valid as it will verify both the existence and severity of the claimant’s injury.
A claimant’s physician can assist in documenting and providing all pertinent medical data.
This physician, however, must meet the SSA (Social Security Administration) definition of an “acceptable medical source.
Here are some acceptable medical sources:
- Licensed physicians (both medical and osteopathic doctors)
- Licensed or certified psychologists*
- Licensed podiatrists (in cases involving the functionality, or degree of impairment, of patients’ foot or ankle)
- Licensed optometrist (in cases involving the functionality, or degree of impairment, of patients’ eyes / vision)
- Speech pathologists licensed by their respective state’s education agency (to determine whether or not speech impairments prohibit the claimant from work)
*In school settings, determining mental retardation / learning disabilities is the responsibility of whichever professional acts as school psychologist. With cases involving children, often the input from non-licensed or non-medical relations are taken into account. Teachers, caregivers and parents can contribute valuable information pertaining to a child’s behavioral patterns in relation to their peers.
Types of Acceptable Evidence For Social Security Benefits
Your personal physician will have the clearest and most extensive knowledge of your situation and the extent of your impairments. Because of this, SSA boards often place preferential treatment on the medical data provided by these treating sources. Thorough, accurate, and timely reports from such a physician often eliminates the need for other medical evidence becoming necessary. A patient history or hospital chart may not tell the full story so personal doctors can provide anecdotal supporting evidence that may help illuminate your case. The SSA will also require information from any other clinic or health facility you may have visited.
Medical Reports should include the following:
- A complete medical history
- A preliminary evaluation of a claimant’s former functionality versus their post-injury / illness functionality
- Test findings, lab results, etc.
- Initial diagnosis
- All treatments prescribed
- Developments and ongoing prognosis
- Updated prognosis regarding work ability
- Mental health evaluations
- Rudimentary motor skill evaluation in children under the age of 18
Consultative examination (CE) reports will include the following data:
- Details of the claimant’s injury / illness / complaint in question
- All pertinent medical data, including any anomalous findings, or lack thereof
- The diagnosis and prognosis of the claimant
- Any prior complaints filed by claimant
- The consultant’s consideration / explanation
- An evaluation of the claimant’s abilities as it pertains to their job functionality:
- Over the age of 18: It should surmise the extent of the claimant’s ability to work. This is not limited to physical labor. All potential work-related activities should be evaluated including hearing, seeing, speaking, sitting, standing, walking, handling / lifting objects.
- Over the age of 18, and mentally handicapped: This evaluation should state to what extent an adult is able to carry on interpersonal relations, interact in a workspace, and process / carry out instruction.
- Under the age of 18: This evaluation should compare the behavior of children to those in their peer group.
Consultative examinations may become necessary if, after the above information is submitted, the claim is still unclear and the administration is unable to determine absolutely the severity of the injury or illness. Once again, the personal physician is the go-to for all examinations if they are willing to provide one for the sanctioned fee. If the claimant prefers another physician, or a better option is clearly available, or the personal physician is not equipped or does not agree to perform the examination, the duties may be conferred to a third-party physician.
Evidence related to a claimant’s symptoms may also be required to round out the case.
Evidence of this type generally includes:
- A claimant’s daily activities
- A claimant’s consumption habits
- The causal factors of a claimant’s injury or illness
- The aggravating factors of a claimant’s injury or illness
- The area, length, frequency, and intensity of pain
- A claimant’s treatment history
- The type and dosage of medication prescribed to the claimant
If you have any additional questions, feel free to contact our NYC Social Security Disability Attorneys for a free consultation.