How to Request Medical Records for Social Security Disability

Whether you are trying to get Social Security disability benefits without a lawyer or working with an attorney, you may have to get your own medical records.

Episode 2 of Disability Tips walks you through how to get your records from your doctor’s office including the following:

  • When to request medical records?
  • What medical records to ask for?
  • How far back to go?
  • How to save your hard-earned money when requesting records (and especially hospital medical records).

Continue reading How to Request Medical Records for Social Security Disability

A perfect recipe for a Social Security disability case?

I had a great back and forth discussion with one of my readers in the comments about how different evidence affects a Social Security disability case. Here is part of the comment:

If you go to a mental health clinic for disabling mental impairments. They usually score you and document how impaired you are and what your level of functioning is. So, I would think it would be easier getting your case approved for a mental health disability if the mental health clinic has documentation showing you have extreme low level of functioning vs. someone applying for disability for say chronic fatigue or something that is subjective.

There is nothing wrong with this analysis. However, Social Security disability cases are rarely formulaic. Continue reading A perfect recipe for a Social Security disability case?

My Social Security file is missing records

missing pieces

Let’s say you are reviewing your Social Security exhibit file before your disability hearing and you discover that some of your doctor’s (or other records) are not there. I have mentioned before that it is not unusual for the medical records in a Social Security file to be a year or more out of date.

What can you do if the records are not complete?

You can ask Social Security to update the records. If you do not have a lawyer Social Security has a higher responsibility to make sure that your hearing is fair, which includes helping you obtain sufficient records to review your case.

Be clear with your request. If you are missing records from a particular doctor, say,

Dr. Smith’s records are missing. Dr. Smith treated me for my back problem from 2001 to 2009 and performed my back surgery. Can Social Security request these records.

If Social Security only has a partial set of records, tell them:

I see you have Dr. Jones records from April 4, 2006 through September 2008, but you are missing her records after September 2008. These records are important because …. Can Social Security request these records?

It is important to tell Social Security why the missing records are important. Social Security does not require every single piece of medical evidence to decide your case. If you want Social Security to get your records, help them understand why those records are critical.

There’s one more thing: even though Social Security has a greater obligation to unrepresented claimant’s (that’s you), it is not Social Security’s duty to obtain evidenceYou have the duty to provide evidence to prove your disability.

So, don’t go demanding that Social Security get this or get that, or get all your records for the last 30 years. It won’t get you anywhere.

Be respectful, explain why the records are critical in a fair evaluation of your case and ask for help.

Reviewing your Social Security exhibit file – Part 1: Medical Records

medical records

How do you begin to review your Social Security exhibit file? Here is a quick guide to finding the really important parts.

Start with the “F” section to review the medical records.

Social Security Administration - Exhibit List Index 2

If you do not review anything else in the file, you need to know what medical records are there (and what records are missing).

Here is what I look for:

  • Are all the doctors and hospitals listed? If the doctor or hospital is not listed, it is a safe bet that those records are not in the file. There are some exceptions to this. Occasionally, records are commingled, with more than one doctor’s records in one exhibit, but that is usually straightened out as the Office of Disability Adjudication and Review (ODAR) gets your exhibit file ready for the hearing.
  • Are all all the dates of service complete? In the image above the records cover August 19, 2003 through November 13, 2003. If you know you treated with that doctor in 2004, you know the records are not complete.
  • Do the number of pages look right? If you were treating with the same doctor for years and years, but Social Security only shows 12 pages, the records are probably not complete.

Then, start to review the actual records. While a review of the exhibit list can help you quickly spot missing records or other problems, you really have to examine the records to find out what Social Security has (and what might be missing).

The F section of the file also has all the reports from any doctors Social Security sent you to. If you want to see what the consultative examiner had to say, now is your chance to find out!

You will also find the forms from the Social Security technicians describing what limitations they think you have. Social Security often uses this information in deciding your case, so you need to know what they are saying.

Things to watch out for if your case is moved to a new hearing office

I previously wrote about how Social Security may move a case from one hearing office (Office of Disability Adjudication and Review – ODAR) to another to try to ease case congestion and speed up processing.

Usually, there is nothing to worry about when this happens. However, there is something you do need to watch out for. If you are not careful, you could delay the decision in your case, or even reduce your chances of winning.

Continue reading Things to watch out for if your case is moved to a new hearing office

When should I apply for Social Security disability benefits?

Are you struggling with working because of physical or psychological impairments?  Have you stopped working because you just could no longer do the job?

You may be going back and forth on whether to apply for Social Security:

Maybe I will get better.  But, what will I do if I am not able to go back to work?

Filing for Social Security benefits is not something to rush in to.  But, if you are disabled, you should file as soon as you can.

If you wait, you may lose several critical advantages. Continue reading When should I apply for Social Security disability benefits?

Social Security disability tip: how to get your medical records for free!

If you request medical records from a doctor or hospital in Colorado, the maximum you can be charged is set by 6 C.C.R 1011-1, Chapter 2, Part In 2008, the maximum price for medical records is “not to exceed $16.50 for the first ten or fewer pages, $.75 per page for pages 11-40, and $.50 per page for every additional page.”

This can quickly add up!

But, there is a way to get your medical records for free. Continue reading Social Security disability tip: how to get your medical records for free!

Cost of Medical Records Increases More Than 36 Percent!

The State of Colorado has allowed medical records copiers to increase the prices they charge to provide your medical records.

Medical records are one of the foundations of a Social Security case. The main way you establish the existence and severity of a medical condition is through medical records. ALL attorneys whose practice revolves around medical records are going to have to swallow this price increase. It also means that your costs as a client are going up.

Do not blame your attorney. The money is not going into your lawyer’s pocket; it is going to the medical copiers. Continue reading Cost of Medical Records Increases More Than 36 Percent!

How to read medical records in a Social Security case

How do I read medical records?

Whether you are working with a lawyer or are trying to get Social Security disability / Supplemental Security Income (SSI) benefits on your own, you will probably be reading medical records at some point.

Here is a quick primer on how a large portion of medical records are set-up.

Most of the medical records I see from doctors in Colorado, whether from primary care providers, specialists, or other doctors use the SOAP notes system. That is, the notes are divided into Subjective, Objective, Assessment, Plan (or Prognosis): S. O. A. P.

  • Subjective – this is where the doctor notes what you told him/her. What brings you in today? How do you feel? What are your symptoms? How are you reacting to treatment/medications?
  • Objective – this is the signs and findings the doctor can objectively measure. This includes things like x-ray or lab findings, range of motion, or other results or observations.
  • Assessment – this is typically the summary of your diagnosis.
  • Plan – this is the course of treatment the doctor recommends or any changes to your current treatment or medications.

Not all doctors use the SOAP notes system. Hospitals, eye doctors and other medical providers may use other systems, but by being able to recognize the SOAP notes system, you will have a leg up on understanding what your doctor’s records are saying.

The one element missing in most Social Security cases: a medical opinion of limitations

To be found disabled, generally you have to show that you are unable to perform some type of full-time work. This is a simplification of the Social Security disability standard, but it is sufficient for this article.

The most common problem in Social Security disability claims is a lack of a statement of limitations from a doctor.

These statements go by different names:

  • Medical Source Statement (this is the term Social Security uses).
  • Medical Opinion.
  • Statement of Limitations.
  • Statement of Permanent Restrictions.

Whatever it is called, it tells Social Security what you can and cannot do. Social Security uses this to decide whether you are disabled.

Isn’t there a statement of limitations already in my medical records?

Probably not.

Most medical records contain a description of your symptoms, the objective findings, the doctors assessment, and the treatment plan. Most medical records do not have any statement of your limitations.

Continue reading The one element missing in most Social Security cases: a medical opinion of limitations