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Importance of Medical Records

Your medical records are the most important evidence considered by the Social Security Administration.(SSA) in evaluating your social security disability case. In order to be found disabled, you must have a “severe medically determinable impairment (s)”, ie mental or physical condition (s) that interfere with your ability to do basic work-related activities. The physical or mental conditions must be expected to last for 12 months or result in death. Medical records document your longitudinal medical history, symptoms, and, sometimes, your limitations from these severe impairments.

Tell your treating physicians, nurse practitioners, chiropractors, psychiatrists, psychologists, social workers, etc. about all of your medical conditions, symptoms, and limitations, so your medical records will be complete. Attend all scheduled appointments and comply with any recommendations by your treating source such as taking medications, going to physical therapy, getting x-rays, MRIs, CT scans, and lab work done or pursuing referrals with specialists. Treating sources issue reports and summaries that contain your diagnoses, medical history, clinical signs and symptoms, medical findings, and laboratory results.

Some clients will tell us that they cannot afford to go a doctor, psychiatrist, or psychologist, etc These clients believe that SSA will find them disabled after sending them to SSA’s paid consultative physical or psychological examination. But, this is NOT a substitute for regular treatment by your own doctor. It is difficult to win a case based only upon the assessment of a one-time examiner, who may be biased. Please see my blog addressing consultative evaluations at https://www.kathleenflynnlaw.com/1586109502014/blog

Social security regulations 20 CFR 404.1527 (d) and 20 CFR 416.927 (d) state that more weight should be given to the opinion of a treating source (s), who provides a detailed, longitudinal picture of your medical impairments, than to a one time psychological or medical examiner. If you do not have insurance or the funds to see a private physician, the Law Office of Kathleen M Flynn can help you find free or low cost clinics and doctor offices in your area.

The Georgia Department of Labor’s Disability Adjudication Services (DAS) and the Office of Disability Adjudication and Review (ODAR) now require that medical records be submitted electronically with a bar code. Sometimes, our office has to make multiple requests for bar codes. While the medical records can be faxed with a bar code to the Georgia Department of Labor’s DAS, there is an online procedure for submitting scanned medical records to ODAR that our clients could not handle on their own. Our office will obtain, scan, and electronically submit your medical records to provide DAS and ODAR with a complete and updated file. It is very important to inform your representative of every doctor, hospital, mental health clinic, medical center etc. that you have visited for treatment.

Your treatment will depend on what type of disability you have. Some examples of treating sources that you should consider seeing, depending on what your disabilities are, include: primary care physicians, surgeons, psychologists, psychiatrists, optometrists, ophthalmologists, neurologists, orthopedists, pulmonologists, cardiologists, endocrinologists, rheumatologists, speech-language pathologists, physical therapists, podiatrists, and chiropractors. Social security regulations 20 CFR 404.1527 (d) (5) and 20 CFR 416.927 (d) (5) state that SSA generally gives more weight to the opinion of a specialist concerning medical issues related to his or her area of specialty than to the opinion of a source who is not a specialist.

Medical documentation is the most effective way to get your case granted. You cannot get social security benefits by just telling SSA that you are sick and cannot work. At the hearing before the Office of Adjudication and Review (ODAR), some claimants believe that all they have to do is tell the Administrative Law Judge (ALJ) what is wrong with them, and they will receive a fully favorable decision (be found disabled by the ALJ). The ALJ will consider your testimony, but will make a decision based primarily on the medical records in the file.Your word is not enough! You need to engage in regular treatment with a physical or mental health professional. Make sure that you keep the Social Security Administration (SSA) or your representative updated when you change a treating source(s) or visit new ones.

Steady treatment creates an excellent record for SSA to review your claim. Furthermore, if you go to a treating source on a regular basis, he or she may complete our assessment forms on your behalf, which address your work-related limitations. If you have any further questions, please contact the Law Office of Kathleen Flynn at 404-479-4431 or www.kathleenflynnlaw.com

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