Getting Your Doctor's Opinion Into Your Social Security Disability File
Having a detailed report on your symptoms and limitations from your doctor can make or break your disability case.
Your doctor’s opinion is a very important part of your Social Security disability case. Social Security often relies on doctor’s opinions to help decide whether a disability applicant meets the requirements of a disability listing or whether the applicant has the residual functional capacity (RFC) to continue to work.
Whether Social Security will rely on your doctor’s opinion depends on your doctor’s credentials, your relationship to (and history with) your doctor, how your doctor writes his or her opinion, and whether the rest of the evidence in your file supports the doctor’s opinion.
Your Doctors' Credentials
Social Security will review everything that you submit for your case, but they may disregard medical evidence that does not come from an “acceptable medical source.” Acceptable medical sources are:
- licensed medical or osteopathic doctors
- licensed or certified psychologists (including unlicensed school psychologists when the claimant alleges mental retardation, learning disabilities, and borderline intellectual functioning)
- licensed optometrists, for purposes of establishing visual disorders only
- licensed podiatrists, for purposes of establishing impairments of the foot, or foot and ankle only, depending on individual state licensing restrictions, and
- qualified speech language pathologists, for purposes of establishing speech or language impairments only
If your treating doctor is not an acceptable medical source, Social Security may either disregard the doctor's opinion or it may just use the doctor's information to establish the severity of your impairment. For example, you may submit a letter from your chiropractor saying that you have degenerative disc disease that meets a disability listing, but Social Security will disregard that opinion. However, if the chiropractor goes on to say that they have been treating you for years and that you cannot sit or stand for more than 30 minutes at a time, then Social Security may use that information to decide if your condition is serious. (If you are trying to get disability for degenerative disc disease, you will need a diagnosis from an acceptable medical source and medical evidence like MRI’s.)
Your Relationship With Your Doctor
Social Security gives more weight to the opinion of a doctor who has treated you regularly for a long period of time, called a treating physician or doctor. You must show that you have an “ongoing treatment relationship” with a doctor for Social Security to consider that person to be your treating physician. An ongoing treatment relationship means that you have seen the doctor with a frequency that is consistent with the accepted practice for patients with your condition. For example, if you only see your neurologist twice a year for treatment of your MS, Social Security will still consider them to be your treating physician if it is common for patients with MS to be seen by a neurologist twice a year.
If Social Security finds that one of your doctors is a treating physician, then Social Security must defer to the doctor’s opinion unless the agency have a good reason to discount it. If Social Security does not give controlling weight to your treating physician’s opinion, the agency will explain the reason(s) why in its written decision.
If the doctor whose opinion you are offering has only reviewed your records and never examined you in person, or if you have only seen the doctor for the purpose of getting an evaluation to help you with your disability case, then Social Security will give the opinion less weight.
The Contents of Your Doctor’s Opinion
Social Security refers to any letter or statement from a doctor as a "medical source statement." Unless your medical source statement describes your diagnosis, your symptoms, your treatment history, and the limitations imposed by your condition, then you may not win your case even though your doctor thinks you are disabled.
Your medical source statement should specify whether and how you meet a disability listing. For example, if you are trying to prove that your six-year-old child meets the listing for mental retardation, it would be helpful to have a doctor describe the behaviors they have seen in your child indicating severe impairments in social functioning, personal functioning, concentration, and/or cognitive and communicative functioning.
If you have been receiving treatment or taking medications for your condition, your medical source statement should indicate whether any of the treatments or medications were effective. You need to show that you are disabled in spite of treatments and medications. If there are side effects to any of your medications, the medical source statement should describe them. For example, if the only effective treatment for your condition is a medication that makes you too drowsy to function, then Social Security needs to know that.
Finally, but often most importantly, your medical source statement should describe your functional limitations. If you can’t lift much weight, can’t sit or stand for very long, have problems walking or using your hands, are afraid to leave your house, can’t remember instructions, or can’t get along with coworkers, it's essential that your doctor details those limitations.
RFC Assessment Forms
It can be difficult for doctors to write good medical source statements. Instead of asking the doctor to write a letter, it is better to get the doctor to fill out a Residual Functional Capacity (RFC) form. RFC forms are relatively long and involved, so the doctor might charge a fee to do it. However, the fee is probably worth it; if you use an RFC form, you will be certain that the doctor includes the right amount of detail and covers all of the important questions. See these samples of mental and physical RFC Assessment forms.