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The Importance Of A Fully Developed Medical Record

Importance of Fully Developed Medical RecordThe importance Of A Fully Developed Medical Record in SSDI Cases, Article Provided By, Cliff Farrell, Esq. (See Cliff’s profile here).

One of the most common problems in the Social Security Disability benefits (SSD) or
Supplemental Security Income benefits (SSI) claims process is making sure Social Security gets
enough proof of your medical impairments or medical conditions. Many people try not to complain
too much and try to minimize their condition and the pain when talking to doctors, resulting in
medical records that do not show how severe your conditions, your injury, your pain or your
illnesses are in preventing you from working. So here are some of the easiest and most practical
steps you can take to avoid making this mistake:

  1. Keep regular doctor appointments — Make appointments with your doctor to seek treatment for the medical problems and the pain and keep those appointments
  2. See your primary physician — Social Security can give your treating doctor’s opinions a lot of weight – if the doctor has been treating you and knows your medical history than a specialist or someone who is seeing you for the first time.
  3. If your primary physician refers you to a specialist, certainly follow those directions, but provide clear evidence of that referral in your application.
  4. By receiving treatment on a regular basis, you help show that the condition is real and is limiting your ability to do daily tasks or duties of a job.
  5. Follow prescribed medical treatment — Listen to your doctor and carefully follow your doctor’s directions for treating your conditions.
  6. Stop smoking and avoid alcohol or drugs — If your doctors have told you to stop smoking, or stop drinking, listen to the doctors. Otherwise, Social Security may try to deny your claim by finding you are either making your own condition worse, or that you are not following medical advice.  This could include exploring physical therapy, exercise programs, alternative treatments, specialist evaluations, weight loss programs, or other medical options suggested by your doctor. Be careful to follow your doctor’s advice about that program and show documentation that you are working toward progress in that area.

Both the Social Security Administration and the claimant have a duty to develop the medical record.  Being disabled for Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) purposes has a very specific definition:  the person must be unable to work because of a severe physical or mental medical impairment or combination of impairments expected to last at least one year
or result in death.  And, most of the time, that boils down to a decision based on medical evidence.  So, when someone becomes unable to work for medical reasons, medical proof must be submitted to Social Security.  Medical evidence can be submitted at every level of agency appeal.  It is always best to make sure enough evidence is submitted earlier rather than later so the claim is approved sooner and benefits can be paid.

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