May 7, 2018

Medical Records and Social Security Disability

The importance of medical records to a Social Security disability claim cannot be understated. These documents are the primary source of evidence on which the Social Security Administration (SSA) will base its decision. Your medical records provide objective evidence of your disabling conditions and diagnoses. This may include key information such as notes from important procedures, like surgeries, or your doctor’s interpretation of test results and magnetic imaging. For mental health claims, session notes from a therapist or psychiatrist can show the SSA that you are receiving consistent and ongoing mental health treatment and reflect the severity of your condition. Therefore, it is critical that all of this documentation is made available to Social Security to ensure that they have a complete record before them when they make a decision on your disability claim.

At the initial application and reconsideration stages, Social Security will gather your medical records based on the information you have provided them. You will want to make sure that whoever is reviewing your claim at these levels is kept up to date regarding the medical providers you have seen and the dates of any future appointments. If you have an attorney helping you at these levels, their office can work with your reviewer to ensure that they have all of the information needed to obtain any outstanding medical records.

A complete medical file is especially important when preparing for a hearing before an Administrative Law Judge (ALJ). The wait time to get to a hearing can be quite long, so it is essential to keep your attorney informed of any changes to your treatment, including any new procedures or diagnoses, which may occur during this time period. These updates allow your attorney to keep track of your treatment providers during the wait, which can help prevent details from being forgotten when it comes time to prepare for the hearing. Once a hearing is scheduled, you should compile a list of the medical providers you have seen. Your attorney can check this list against what is already in your file to determine what medical records must still be obtained to complete the file before the hearing. Some medical providers can take over a month to produce records, so it is important to provide this information to your attorney without delay. You want the ALJ to have all of the facts at their disposal when you arrive to your hearing.

Sometimes, despite best efforts, it may prove impossible to obtain records from some medical providers before a hearing. Your attorney should know the proper correspondence to file with the ALJ to comply with Social Security’s rules on submitting medical evidence, and this opens the possibility that the judge will consider medical records that come in after the hearing. Experienced disability attorneys will also have knowledge of the local healthcare systems and what must be done to obtain records from specific providers. If you have questions about how your medical records relate to your Social Security disability claim, consult a qualified disability attorney for more details.

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