MusicCityDisability.com Social Security Disability Attorneys William B. Sloan Andrew N.

Egan 4636 Lebanon Pike, #186 Hermitage, TN 37076 615-787-7170 PRESENTING MEDICAL EVIDENCE IN SOCIAL SECURITY DISABILITY APPEALS As you have probably already discovered, the Social Security Disability application process is difficult and sometimes overwhelming for applicants. Our Job is to help you accumulate your best medical evidence and present the evidence and the law to Social Security. Medical Evidence Under both the SSI and SSDI programs, medical evidence is critical for the determination of disability. Each person who files a disability claim is responsible for providing medical evidence showing he or she is disabled under the law. However, one of our responsibilities is to help you get medical reports from your own doctors and hospitals that have treated you. In most cases, we request your doctor to fill out a few short forms that highlight your particular disabilities. Medical Sources It is important that your medical sources are recognized by Social Security. Example: Chiropractors are not a valid medical source under the Social Security guidelines.

Acceptable Medical Sources licensed physicians (medical or osteopathic doctors); licensed or certified psychologists including school psychologists (and other licensed or certified individuals with other titles who perform the same function as school psychologists in a school setting) only for purposes of establishing mental retardation, learning disabilities, and borderline intellectual functioning ; licensed optometrists only for purposes of establishing visual disorders (except in the U.S. Virgin Islands where licensed optometrists are acceptable medical sources only for the measurement of visual acuity and visual fields); licensed podiatrists only for purposes of establishing impairments of the foot, or foot and the ankle, depending on whether the State in which the podiatrist practices permits the practice of podiatry on the foot only, or the foot and the ankle; and qualified speech-language pathologists only for purposes of establishing speech or language impairments. For this source, qualified means that the speech-language pathologist must be licensed by the State education agency in the State in which he or she practices, or hold a Certificate of Clinical Competence from the American Speech-Language-Hearing Association. Medical Evidence from Treating Sources Most of our clients disability claims are decided based on medical evidence from treating sources. SSA regulations place special emphasis on evidence from treating sources because they are likely to be the medical professionals most able to provide a detailed longitudinal picture of the claimant's impairment(s) and may bring a unique perspective to the medical evidence that cannot be obtained from the medical findings alone or from reports of individual examinations or brief hospitalizations. Therefore, timely, accurate, and adequate medical reports from treating sources accelerate the processing of the claim because they can greatly reduce or eliminate the need for additional medical evidence to complete the claim. Medical Evidence From Health Facilities SSA will requests copies of medical evidence from hospitals, clinics, or other health facilities where you been treated. We will review the medical evidence SSA requests, and we will request any records SSA is missing. Other Evidence

Information from other sources may also help show the extent to which your impairment(s) affects your ability to function in a work setting; or in the case of a child, the ability to function compared to that of children the same age who do not have impairments. Other sources include public and private agencies, nonmedical sources such as schools, parents and caregivers, social workers and employers, and other practitioners such as naturopaths, chiropractors, and audiologists. Medical Reports Physicians, psychologists, and other health professionals are frequently asked by SSA to submit reports about your impairment(s). Therefore, it is important to know what evidence SSA needs. Our job is to make sure SSA has all the reports they need to make their decision. Medical reports should include: medical history; clinical findings (such as the results of physical or mental status examinations); laboratory findings (such as blood pressure, x-rays); diagnosis; treatment prescribed with response and prognosis; a statement about what the claimant can still do despite his or her impairment(s), based on the medical source's findings on the above factors. if the claimant is an adult age 18 or over, this statement should describe, but is not limited to, the claimant's ability to perform work-related activities, such as sitting, standing, walking, lifting, carrying, handling objects, hearing, speaking, and traveling. In adult cases involving mental impairments or mental functional limitations, this statement should describe the claimant's capacity to understand, to carry out and remember instructions, and to respond appropriately to supervision, coworkers, and work pressures in a work setting. If you are applying for a child under age 18, this statement should describe the childs functional limitations compared to children his or her age who do not have impairments It is our job to describe the childs ability to acquire and use information, attend and complete tasks, interact and relate with others, move about and manipulate objects, care for his or her self, and his or her health and physical well-being.

Consultative Examinations SSA may request a Consultative Examination to determine if you are disabled. Additional medical information may be sought by re-contacting the treating source for additional information or clarification, or by arranging for a consultative examination. Your doctor is the preferred source for a consultative examination if he or she is qualified, equipped, and willing to perform the examination for the authorized fee. Most doctors do not wish to perform the consultative examination. Even if only a supplemental test is required, the treating source is ordinarily the preferred source for this service. However, SSAs rules provide for using an independent source (other than the treating source) for a CE or diagnostic study if: the treating source prefers not to perform the examination; the treating source does not have the equipment to provide the specific data needed; there are conflicts or inconsistencies in the file that cannot be resolved by going back to the treating source; the claimant prefers another source and has good reason for doing so; or we know from prior experience that the treating source may not be a productive source. Consultative Examination Report Content A complete CE report will involve all the elements of a standard examination in the applicable medical specialty and should include the following elements: your major or chief complaint(s); a detailed description, within the area of specialty of the examination, of the history of the major complaint(s); a description, and disposition, of pertinent "positive" and "negative" detailed findings based on the history, examination, and laboratory tests related to the major complaint(s), and any other abnormalities or lack thereof reported or found during examination or laboratory testing; results of laboratory and other tests (for example, X-rays) performed according to the requirements stated in the Listing of Impairments (see Part III of this guide); the diagnosis and prognosis for the claimant's impairment(s);

a statement about what you can still do despite his or her impairment(s), unless the claim is based on statutory blindness. If you are an adult age 18 or over, this statement should describe the opinion of the consultant about the your ability, despite your impairment(s), to do work-related activities, such as sitting, standing, walking, lifting, carrying, handling objects, hearing, speaking, and traveling; In adult cases involving mental impairment(s) or mental functional limitations, this statement should also describe the opinion of the consultant about the claimants capacity to understand, to carry out and remember instructions, and to respond appropriately to supervision, coworkers, and work pressures in a work setting. if the claimant is a child under age 18, this statement should describe the opinion of the consultant about the child's functional limitations compared to children his or her age who do not have impairments in acquiring and using information, attending and completing tasks, interacting and relating with others, moving about and manipulating objects, caring for yourself, and heath and physical well-being. The consultant 's consideration, and some explanation or comment on, the claimant's major complaint(s) and any other abnormalities found during the history and examination or reported from the laboratory tests. The history, examination, evaluation of laboratory test results, and the conclusions will represent the information provided by the consultant who signs the report. Evidence Relating to Symptoms In developing evidence of the effects of symptoms, such as pain, shortness of breath, or fatigue, on a claimant's ability to function, SSA investigates all avenues presented that relate to the complaints. These include information provided by treating and other sources regarding: your daily activities; the location, duration, frequency, and intensity of the pain or other symptom; precipitating and aggravating factors; the type, dosage, effectiveness, and side effects of any medication; treatments, other than medications, for the relief of pain or other symptoms; any measures the claimant uses or has used to relieve pain or other symptoms; and other factors concerning the claimant's functional limitations due to pain or other symptoms.

In assessing your pain or other symptoms, the decision makers must give full consideration to all of the above-mentioned factors. It is important that medical sources address these factors in the reports they provide.