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Medical Records to win SSDI and SSI

Most disability applicants realize the application and disability determination process can be very long. Getting the right information to the SSA can and accurately completing the application obviously can increase an applicant’s chances of winning SSDI or SSI the first time they apply. One of the most common questions we get on our disability forum is, “What documentation does the SSA need to determine I am disabled?”

Basic SSI and SSDI application information:

The Social Security has identified the basic information that all applicants need prior to completing the application and the Adult disability report as follows:

  1. Your Social Security number;

  2. Your birth or baptismal certificate;

  3. Names, addresses and phone numbers of the doctors, caseworkers, hospitals and clinics that took care of you and dates of your visits;

  4. Names and dosage of all the medicine you take;

  5. Medical records from your doctors, therapists, hospitals, clinics and caseworkers that you already have in your possession;

  6. Laboratory and test results;

  7. A summary of where you worked and the kind of work you did; and

  8. A copy of your most recent W-2 Form (Wage and Tax Statement) or, if you are self-employed, your federal tax return for the past year.

After the SSA has your application they will verify that you meet the basic nonmedical requirements for SSDI or SSI. If you have applied for SSDI they will also verify your work history. If you meet the nonmedical requirements your disability file is sent to the appropriate disability determination services office in your state.

What medical documentation will the SSA need to determine I am disabled?

Unfortunately, the information above will not allow the SSA to make a disability determination. During the SSDI or SSI application process you will have to complete forms which also describe your medical condition and how it affects your ability to work. The SSA may also request information from your doctors or medical professionals who have treated you, although they may or may not be willing to complete these forms. Having information from your doctors is very helpful, but if a doctor is not willing to provide additional information to the SSA can the SSA can still use just your available medical records to determine you are disabled.

What is information is the DDS looking for?

The disability determination services office will request your medical records from your treating sources. As they review your medical records they will need the following information:

  1. What your medical condition is;

  2. When your medical condition began;

  3. How your medical condition limits your activities;

  4. What the medical tests have shown; and

  5. What treatment you have received.

The SSA will not ask your doctors if you are disabled nor will they accept a note from your doctor stating you are disabled as absolute proof of disability. They are actually looking for medical evidence which supports your claims about your limitations to work. For example, if you claim you cannot sit, walk or stand for extended periods of time they would expect your medical records to provide evidence of this fact.

So, back to the question, “What medical evidence do I need to prove my disability?” Unfortunately, there is no one answer. Your medical evidence needs to answer the questions listed above. Will this take seeing multiple doctors and having pages and pages of documentation? Maybe but it really means you need to focus on seeing the right doctors and making sure they clearly document your limitations to work.
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