To successfully support a Social Security Disability (SSD) claim, it's essential to gather comprehensive and relevant medical evidence. The Social Security Administration (SSA) relies mostly on your medical records to determine if your condition qualifies for disability under their rules.
To prove a claim for SSD claim, the onus is on the person claiming the benefits. In English, that means you and I must prove you cannot work. SSA judges do not believe a claimant when you assure them you cannot work. To convince them, we need to create a medical record of treatment, medications, and medical opinions that support your “I can’t work” statement.
Medical Evidence is Crucial for Your Disability Claim
So, how do you do that? The most obvious thing is if you are going to claim a condition keeps you from working, then you need to have treatment for that condition. You cannot tell a Social Security judge that Anxiety or Depression keeps you from working if you have no treatment for Anxiety and Depression.
And, no, taking a pill is not treatment. The SSA judge knows plenty of people in their life, perhaps even in their office, who take a pill for Depression and are able to work just fine. If you are going to claim a condition bothers your ability to work, then you need to see someone who specializes in treating that condition. In the case of seizures, that means a Neurologist. Back pain? An orthopedist. Depression? A therapist.
Here's a breakdown of other medical documentation you'll need for your successful SSD claim:
Which Medical Records Should be Submitted to the SSA?
These medical records are the foundation of your claim and should include:
- Diagnosis reports from licensed medical professionals
- Office visit notes from treating physicians
- Hospital records, including ER visits and discharge summaries
- Lab results (e.g. blood work, imaging results like X-rays, MRIs, CT scans)
How a Physician's Statement or Medical Opinion Helps Your Case
Also called a Residual Functional Capacity (RFC) assessment, this document should detail:
- Your diagnosis
- Symptoms and severity
- Physical or mental limitations (e.g. standing, walking, concentrating, interacting with others)
Best Practice: Get an RFC form filled out by a specialist treating your specific condition (e.g. neurologist, psychiatrist).
Documenting Your Treatment History and Medication Use
SSA values a treating history with a medical professional versus a single evaluation. Your treatment history is not necessarily doctor visits from two decades ago, but from the period you claim you were disabled. Those records should include:
- Treatment attempts and changes in therapies over time
- Medications and their side effects and impact on daily functioning
Why Treatment Compliance Matters to SSA Judges
Demonstrate that you've followed your doctor's treatment plan or provide a valid reason if you haven't (e.g. side effects, financial barriers). Non-compliance can hurt your claim unless it is justified.
The Social Security Attorneys of Keller & Keller Are Here to Help
Luckily for you, the Keller & Keller Disability Department has a number of attorneys who represent people all over the United States, but specialize in Indiana, Illinois, Wisconsin, and New Mexico. SSA judges in our practice areas know and trust our attorneys and their decades of experience. We can help you determine which medical professionals to contact for opinion evidence and are experts in putting together cases which are consistent with SSA regulations and judges’ expectations.
I have personally dealt with Disability claims for more than 30 years. I am confident in my and my department’s ability to obtain record from your treating sources. After that, we will develop the case to make it as strong as possible. You can trust our department will help you every step of the way to proving your case.
