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When the SSA reviews your initial disability claim, it obtains your medical records, and determines your residual functional capacity after analyzing those records. The problem with this approach is that the SSA does not obtain your doctor's opinion about your limitations. Rather, the SSA reviews your medical records and makes its own determination.

However, a doctor's treatment notes are intended to manage a patient's medical care, not to establish the functional limitations that Social Security uses to evaluate a claimant's ability to work. As a result, the method used by Social Security to evaluate claims often results in a denial of the initial claim for disability benefits, because often your functional limitations usually are not clear from a review of your medical records.

To remedy this situation, it is very important to obtain your doctor's opinion regarding your physical and/or mental limitations, and how those limitations affect your ability to work. A medical source statement from your doctor setting forth your limitations due to your impairments is usually the most powerful medical evidence in support of your disability claim.

In general, an administrative law judge will give greater weight to the opinion of a treating physician, as opposed to a doctor who examined the claimant just one time, or never at all. However, a judge is not obligated to accept the opinion of a treating physician. Rather, the judge must consider several factors when evaluating a treating medical source opinion. See 20 CFR 404.1527(c). 

When Social Security receives your disability claim, it reviews your medical records, and makes a determination on your claim. The SSA rarely obtains your doctor's opinion about your work-related functional limitations.

Rather, the SSA makes its own determination of your functional limitations. An in-house doctor infers your limitations from your medical records and the disability claim file, and completes an RFC form. 

The problem with this approach is that a doctor's treatment notes are intended to manage a patient's medical care, not to establish the functional limitations that Social Security uses to evaluate a claimant's ability to work. As a result, the method used by Social Security to evaluate disability often results in a denial of the initial claim.

Further, the in-house doctors at Social Security are reviewing hundreds and hundreds of claims. It is difficult to make your true limitations stand out in such an environment.

To remedy this situation, it is very important to obtain your doctor's opinion regarding your physical and/or mental limitations, and how those limitations affect your ability to work.  A medical source statement from your doctor setting forth your limitations due to your impairments is often the most powerful evidence in support of your disability claim.

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In a recent blog post entitled “Get It Written Down!” Chicago disability attorney Aaron Rifkind tells the story of a claim that was granted quickly due to the completeness of his client’s medical records.

I told her that it was because of her thorough medical records that we were able to win so quickly. She responded, “My records are so thorough because every time I go to the doctor, I tell him to make sure to write down everything I tell him, every complaint, and every pain I have, if you don’t do that then no one will ever know what you have.” And you know something, she is right!

One of the best things an individual can do when applying for Social Security disability benefits is to make sure that all of the complaints and medical issues are in writing.

This is an important point. Be sure to tell the doctor your symptoms, and make sure that your doctor writes them down.

Your medical records – the doctor’s treatment notes and progress notes – are maintained to keep track of your medical care, as a tool to assist your doctor with your treatment. Those notes are not created to be used for the purpose of establishing a disability claim. However, your medical records are the principal evidence for your Social Security disability claim, and the symptoms listed in your records will be used by the Social Security Administration to assess your work-related limitations.

In general, doctors do not focus on how your symptoms affect your daily activities. You should tell your doctor about your symptoms and how they affect your life. This information will help your doctor better understand your medical condition. The resulting medical record may also help your disability case, since your symptoms and their effects on your activites will end up in the doctor’s progress notes, and those notes will be used by SSA to establish your work-related limitations.

Be specific. Instead of saying to the doctor “my back hurts when I stand too long,” say “after 15 minutes of standing my back hurts so much that I have to sit down for 15 minutes.” Give the doctor some specific details to describe the effects of your medical condition. The same is true for mental limitations, such as depression or anxiety. Rather than saying “my depression is a little better (or a little worse) this month,” say “I was so depressed that I could not leave the house for 6 days last month.” Give your doctor some specifics. And make sure the doctor writes it down.

I send a medical source statement to the claimant's doctor in pretty much every case, because it is the most powerful evidence available of the claimant's functional limitations. Social Security's rules put the opinions of treating physicians at the top of the hierarchy of medical evidence. See 20 CFR 404.1527(d) and Social Security Ruling 96-2p. A good medical source statement is often the difference between winning and losing a disability claim. I cannot overstate its importance.

Now, doctors are busy, and primary care doctors are very busy, and in general they do not like completing these forms. They are not paid for it, either. But lately I have noticed an uptick in doctors avoiding the task of completing the form by saying that it requires a functional capacity evaluation (FCE). 

Functional Capacity Evaluation

A functional capacity evaluation is performed by a physical therapist by actually physically testing the patient. FCEs have become a big business. The inherent flaw in the FCE process, however, is that physical testing for a day or two cannot reliably predict what the patient can do on a regular and continuing basis in the workplace. Drawing conclusions about residual functional capacity from an FCE is closer to voodoo than science. 

Social Security's medical source statement form does looks like it requires a FCE, because it has precise categories for lifting and carrying, standing and walking. So you can see how a misunderstanding could develop at the doctor's office about the nature of the form. But sometimes, the FCE issue is just a convenient excuse to avoid completing the form. 

An FCE can help your case, but not the way a medical source statement can. An FCE is not from your treating physician, so it is not entitled to the deference of 20 CFR 404.1527(d)(2). It may not be from a physician at all, so you now have a non-acceptable medical source issue. See 20 CFR 404.1513.

Most importantly, a functional capacity evaluation does not address the critical issue of what the claimant can do on a sustained basis. An assessment of what you can do on a given day has little to do with what you can do day after day or week after week. The FCE doesn't tell you that, and that's what an residual functional capacity must determine. See Social Security Ruling 96-8p.

Get a Medical Source Statement instead

What the medical source statement requires, as the name implies, is a doctor's opinion – a medically informed opinion about what the claimant can and can't do. Knowledge of the patient's medical condition and common sense are all that is required.

By the time someone from the doctor's office calls me to say that an FCE is required to complete the medical source statement, it is usually too late to persuade them otherwise. I deal with this situation now by involving the client. I tell the client that the doctor will not complete the form, and would they please take the blank form with them to their next doctor's visit. At the next visit, with the patient right there in front of the doctor, the form is usually completed. But if you are not careful, a hearing can be scheduled before the next doctor's appointment, and you can miss the opportunity for this type of patient intervention.

What is the solution?

  • This issue requires outreach to physicians. I mention it whenever I talk to a doctor, but I don't talk with doctors that frequently. I would like to address local meetings of physicians to spread the word. The issue is too important to just let the situation get worse.
  • I always thank the doctor when I get a form back. I think positive reinforcement helps.
  • I may start paying to have the form completed, and simply send a check for $50 to the doctor's office with the blank form. But this cost gets passed on to the client at the end of a successful case, and I am reticent to make this my standard practice.
  • I am considering abandoning the Social Security medical source statement form, SSA form HA-1151-BK. I mean let's face it: the form does look like it requires a functional capacity evaluation. I may create a different form, or request more narrative reports from doctors. Narrative reports take more of a doctor's time, and are correspondingly difficult to obtain, but at least there is no easy excuse to avoid giving an opinion.

I would welcome your suggestions. What do you do to obtain medical source statements? Please leave a comment.


In a recent post entitled Treatment Records, New York disability attorney Jeffrey Delott stated:

Treatment notes basically serve as a way to remind the physician of things she or he may need to remember at a follow up visit. Many relevant physical exam findings are not included either because, for example, they may have been previously reported and would be redundant, are obvious such as walking with a cane, or are implied, such as trigger points for fibromyalgia. Claims adjudicators frequently try to deny a claim by relying on treatment notes’ omissions as evidence that a person lacks “objective evidence” to support a claim. Therefore, it needs to be pointed out that treatment notes do not serve the same purpose as a narrative or other disability report, which is why they may appear different.

Mr. Delott is right. A doctor’s progress notes are maintained to keep track of the patient’s medical care. They are not created for the purpose of establishing disability. That is why a doctor’s progress notes alone are often not sufficient in a Social Security disability claim. An opinion from the doctor is often required. And the doctor’s opinion may assess limitations that are not noted in the patient’s treatment records. That is not unusual, because the treatment records have a different purpose than a doctor’s opinion letter or medical source statement.

Be sure to tell your doctor about your functional limitations, and hopefully those limitations will find their way into the doctor’s progress notes. But you should understand that your medical records alone may be insufficient to establish the functional limitations that Social Security uses to assess your claim.

I recently came across this website for two Florida chiropractors who are holding themselves out as Social Security disability specialists representing Social Security disability claimants nationwide.

The site repeats this statement several times: The Social Security Administration requires that, "You must prove the MEDICAL condition, NOT the legal reason why you cannot work." The clear implication is that a doctor would be a better choice than an attorney to handle a Social Security disability claim. 

I must disagree. Here are 7 quick reasons why:

  1. Proving your medical condition is just the beginning of a successful Social Security disability claim. You must then prove that your medical condition either meets a listed impairment or prevents you from working. (see Social Security's sequential evaluation). Either approach requires interpreting Social Security's extensive regulations and rulings, which is squarely the province of a lawyer.
  2. A Social Security claim requires one to develop a winning theory of the case and then develop evidence in support of that theory. Legal training is central to these tasks.
  3. Representing a claimant requires determining how the detailed Social Security regulations interact with the unique facts of a particular claim. Applying the law to the facts of a case is what lawyers do.
  4. A Social Security claimant's representative must persuade the decisonmaker that the claim should be granted. Persuasion is what lawyers do.
  5. I write a prehearing memorandum for every case, explaining to the judge why the claim should be granted under Social Security's rules. Lawyers are trained writers.
  6. The judge is a lawyer. Who do you want sitting next to you at the hearing?
  7. Should your claim be denied at the hearing level, you can appeal to the Appeals Council and, when necessary, file suit in U.S. District Court. You won't see any doctors there.

That's the first 7 reasons that came to mind. I am sure that there are others. If you have another reason, or if you disagree, please leave a comment.

A medical source statement is an important piece of evidence in a Social Security disability claim. The opinion of your treating doctor regarding your functional limitations should be given controlling weight by the SSA, if the opinion is not inconsistent with the other substantial evidence in the case record. 20 C.F.R. 404.1527(d)(2).

Social Security has a form, entitled Medical Source Statement of Ability to do Work-Related Activities (Physical), for a treating doctor to give an opinion regarding a patient's functional limitations for a Social Security claim. The form is not available on Social Security's website, and it is hard to find anywhere online.

Here is the version of HA-1151 that I use in my Social Security disability practice. Download form HA-1151.

Warning: be careful with this form! If your doctor gives Social Security an opinion regarding your limitations that still allows for employment at the sedentary exertional level, your claim could be worse off with that opinion than without it. It depends upon your particular situation. Do not have your doctor complete the form and blindly send it to Social Security. Get help from a Social Security disability attorney first.

Colorado Springs disability lawyer Tomasz Satasiuk has published an article on his Colorado Social Security Law blog entitled Should I see a specialist when applying for Social Security Disability?

Tomasz and I agree that the answer is: YES!

Depending upon your impairment, a specialist's opinion can be very important both for your medical care and for your Social Security disability claim.

Three particular situations come to mind:

  1. If you suffer from fibromyalgia, it is very important to get that fibromyalgia diagnosis from a rheumatologist. The American College of Rheumatology sets forth the diagnostic criteria for fibromyalgia. There is a world a difference between a rheumatologist's diagnosis of fibromyalgia and your primary care doctor's diagnosis of a "fibromyalgia-like syndrome."
  2. If you have Lyme disease, you should see an infectious disease specialist who specializes in Lyme disease. Such expertise is very important both for your medical care and for your disability claim.
  3. If you suffer from a mental impairment (such as anxiety, depression or bipolar disorder), it is very helpful to have a psychiatrist or psychologist involved in your medical care. In my view, if your family doctor is the only one treating your severe anxiety and depression, you will have problems with your Social Security disability claim.

That's just three situations that come up over and over again in my practice. There are certainly others.

In addition to more focused medical care for you, a specialist's opinion is given greater weight by the SSA. See 20 C.F.R. 404.1527(d)(5).

This question brought a recent visitor to this blog: Does a medical statement from my doctor help with social security disability?

The short answer is YES! A medical source statement from your treating physician regarding your functional limitations is usually the most powerful evidence available for a Social Security disability claim.

It is not just common sense that your treating doctor knows you best. Social Security regulations (see 20 C.F.R. 404.1527(d)(2) and Social Security Ruling 96-2p) state that your doctor's opinion, in ordinary circumstances, is more important than the opinions of other doctors who may have examined you just once, or not at all.

A medical opinion from the treating doctor is so important that when I receive one, I write a handwritten note to thank the doctor for taking the time to complete the medical source statement. I actually have special stationery for this. I want to let the doctor know just how important the opinion is for the patient's disability claim, and how much the effort is appreciated. I do this because medical source statements win claims.

A medical source statement from your treating doctor is a crucial piece of evidence for your Social Security disability claim.

Veterans applying for Social Security disability often receive all their medical care through the VA. It has been a challenge (to say the least) to get VA health care providers to complete Social Security assessment forms.

As an example, look at the letter I received from the Manchester VA hospital after asking the treating PA to complete form HA-1151-BK, which is the official Social Security form for a medical source statement of ability to do work-related activities (physical). The VA letter basically says "It is not our job to do these forms."

Well, the VA has a new directive explaining that VA policy requires medical providers to complete medical assessments for their patients. The directive states that VA providers are required "to honor requests by veterans for assistance in completing non-VA forms regarding their current health conditions and functional impairment." The directive expressly lists Social Security forms among those that must be completed by VA medical providers.

Hat tip to San Francisco Social Security attorney Geri Kahn at the California Social Security Lawyer Blog for writing about the VA's new directive. Geri's post is appropriately titled "Veterans may now find it easier to get their providers to fill out Social Security forms."