Ordering Medical Records

In order to succeed in a Social Security claim, you must have medical documentation. Here is what you need to know, and how Evans & Evans can help you through the process.

To make a determination of disability, the decision-makers at the Social Security Administration need solid medical evidence that proves you are suffering from a severe medical condition.

The condition must prohibit you from working and making more than $1,220 gross income per month. While you will provide information about your treatment and medical providers, Social Security will request the records from hospitals, clinics and other health care facilities.

However, once your case is at the hearing level, Social Security will no longer order medical records for your claim. Evans & Evans will help order your medical records for you. We sit with you and review your file, we go over what Social Security has already gathered,and we make sure to order any new or missing medical information that can help your claim.

While reports and documentation will vary depending on your condition, some records are given more consideration than others.Social Security is selectivewhen it comes to medical records. They will consider records, documentation,and opinions only from “acceptable medical sources”.

This includes:

  • Licensed medical or osteopathic doctors. Chiropractors and/or alternative health care providers such as naturopaths and acupuncturists are not included.
  • Licensed or certified psychologists, including school psychologists
  • Licensed optometrists
  • Licensed podiatrists
  • Qualified speech pathologists

Medical records and reports from acceptable sources should include:

  • Your medical history
  • Clinical findings, such as the results of physical or mental examinations
  • Laboratory findings, such as blood pressure and X-ray results / MRI results
  • Prescribed treatment, including your response and prognosis
  • Medications lists

Medical records should contain enough information from acceptable medical sources to allow Social Security to make an independent decision regarding the nature and severity of your condition.

Generally speaking, your medical records should refer to reports that are fairly recent and are relevant to your current medical condition. If your disability application is denied and you are scheduled for a disability hearing, then it is imperative that you submit any new records, treatment notes and test results to the Administrative Law Judge (ALJ) prior to your hearing. Unlike at the initial application level, Social Security does not gather new records at the hearing level.

In fact, without an attorney, most people at the hearing level are not even aware that their most recent medical records have not been submitted to the ALJ. If you have legal counsel, an experienced disability attorney will take care of this for you.

Evans & Evans works with doctors and other medical providers to make sure your disability claim contains the most up-to-date and relevant information. Our in-depth knowledge of the system and our ability to understand complex medical records will undoubtedly make the process easier for you, and we will maximize your chances of success.