The key evidence for Social Security disability claims is often a medical source statement, which is an opinion from a treating physician (or other acceptable medical source) regarding the functional limitations resulting from your impairments. The doctor's actual progress notes usually do not have meaningful information regarding a patient's functional limitations (my clients are often surprised by this), so an opinion on this issue is quite important for your disability claim. Further, Social Security must give special consideration to a treating source opinion.
However, a medical source statement is not always available. Many doctors will not provide them. I have several clients who go to a New Hampshire pain management clinic, and the clinic simply has a policy not to complete medical source statement forms. Whatever the reason, it is intensely frustrating when you have a disabled client who cannot get a treating doctor's opinion regarding functional limitations.
What can an administrative law judge infer from a lack of a medical source statement? In my view, nothing. There are lots of reasons why a doctor may not choose to complete the form. Nevertheless, I see ALJ decisions where the absence of a medical source statement is cited as a reason supporting an unfavorable decision.
What to do for a disability claim with no medical source statement?
- Try again. Exhaust every avenue to get a medical source statement.
- Beef up the other aspects of the claim, including nonmedical evidence. Consider a statement from a spouse, family member, or friend. Develop any evidence you can that demonstrates disability.
- Explain at the hearing that this particular doctor does not provide these opinions. Don't allow the judge to assume that the doctor does not think that the claimant has significant functional limitations.
Lastly, hope for the best. The absence of a medical source statement gives the judge much more leeway, in my view. Nevertheless, disability claims without a treating doctor's opinion are approved every day.