How to Use a Doctor Disability Letter to Win Your Social Security Disability Case
Your Doctors’ Opinions on Your Physical and Mental Abilities Can Help You Prove That You are Disabled if Your Testimony and Medical Records Support Those Opinions
Medical records are necessary to prepare your Social Security Disability claim. But they are not enough to win in many disability cases – unless you are 55 or older. An extensive disability letter from your treating doctors is often critical proof that you need.
Presenting medical opinion evidence from your treating physicians is often more important than submitting medical records. Your treating health care providers’ opinions are essential to persuading many administrative law judges (ALJs) that you are disabled. Some ALJs ask what attending physician statements you have before taking testimony at the hearing.
This article has two purposes.
First, explain why you should ask your doctor to complete a disability letter or an attending physician’s statement or give their opinion in another format and what your doctor should discuss.
Second, explain to doctors how they can help their patients get approved for Social Security Disability benefits.
Many of the recommendations discussed in this article apply to workers compensation, long-term disability, and even car accident cases. The task of explaining the litigation process and burden of proof to treating doctors, the development and gathering of evidence, and the presentation of attending physician reports to the claim adjuster, judge, and jury are common in all tort claims based on personal injuries.
If you have questions about applying for disability, appealing the Social Security Administration’s (SSA’s) denial, or presenting your case at a disability hearing before an ALJ, call me for a free consultation: (804) 251-1620 or (757) 810-5614. See why my colleagues and former clients have voted me one of the best disability lawyers in Virginia.
Can a Doctor Write a Letter for Disability or Give a Medical Opinion on My Ability to Work?
Yes.
Your treating medical providers (surgeons, doctors, nurse practitioners, psychologists, counselors, etc.) can write letters explaining your disability status and restrictions and limitations.
No federal or state law or regulation prevents your treating physicians from writing letters or otherwise giving opinions stating you are disabled and explaining why.
Some health care providers have policies stating that doctors should complete reports for use in Social Security Disability cases.
For example, the Veterans Administration (VA) encourages its doctors to complete medical opinion reports when their patients request them. Veterans Health Administration (VHA) Directive 1134(2) establishes a policy requiring its health care providers to assist patients in completing VA and non-VA forms regarding their medical conditions and functionality.
Why Does My Doctor Need to Complete Social Security Disability Forms When I Have Submitted the Medical Records?
There are several reasons you should not rely solely on medical records to prove your Social Security Disability claim. These include:
- The claim examiner or ALJ assigned to your case may not review all the medical records you submitted. Some of you may have thousands of pages of medical records. This increases the risk that the claim examiner or judge will miss something important. A doctor’s disability letter summarizes the important information and puts it in one place.
- Medical providers focus on treating you and helping you get better. They do not focus on litigation or disability claims. Therefore, your medical records may not discuss the things the SSA looks for when deciding that an applicant is disabled.
Who is Responsible for Getting a Doctor to Complete Disability Forms?
You are.
Social Security Ruling 17-4p is titled Responsibility for Developing Written Evidence.
The Ruling’s purpose is to clarify the SSA’s responsibilities and those of disability claimants and their attorneys to develop evidence in disability and blindness claims under the Social Security Act.
It states:
Although we take a role in developing the evidentiary record in disability claims, claimants and their appointed representatives have the primary responsibility under the Act to provide evidence in support of their disability or blindness claims.
Relying on the SSA to develop the evidentiary record and get the medical opinion source statements is risky. Take control of your case by working with your doctors to get the reports you need.
How to Get a Medical Opinion on Disability from Your Doctor
Your doctor’s medical opinion on disability can come in many formats. These formats include:
- Ask your doctor to present live testimony at the disability hearing if they prefer. It is uncommon for treating doctors to testify in disability cases, but it is a possibility.
- Take your doctor’s deposition. You can record your conversation with the doctor in person or by telephone, then transcribe the recording and ask the doctor to sign it. You can also hire a court reporter to record the conversation and transcribe it.
- Send interrogatories (specific written questions) to the doctor and submit the doctor’s answers. Only send interrogatories if you have discussed them with your doctor, and you know the responses will help your case.
- Discuss your medical impairments and disability status with your doctor. Then write a letter summarizing the discussion and send it to your doctor to sign.
- Send a letter to your doctor explaining how the SSA defines the term “medical opinion” and asking your doctor to write a disability letter.
- Send a blank Residual Functional Capacity (RFC) form to your doctor. I use sample disability forms for physical restrictions, mental limitations (depression, anxiety, schizophrenia, bipolar disorder, etc.), and specific medical conditions such as: Back Injury/Lumbar Spine, Bladder Problem, Cancer, Cervical Spine Disorders, Chronic Fatigue, Complex Regional Pain Syndrome (CRPS)/Reflex Sympathetic Dystrophy (RSD), Diabetes Mellitus, Dizziness, Fibromyalgia, Headaches and Migraines, Heart Disease and Cardiac Disorders, Lupus, Major Dysfunction of a Peripheral Joint (shoulder injury knee injury, etc.), Muscular Dystrophy/ALS, Neurological Disorders (including those resulting from traumatic brain injury, a concussion or head injury, skull fracture, or post concussion syndrome), Obesity, Peripheral Neuropathy (numbness, tingling, radiating pain), Post Cancer Treatment, PTSD, Seizures, Spinal Nerve Root Compression, Reconstructive Surgery of a Joint (partial or total joint replacement), Spinal Stenosis (requiring a spinal fusion surgery), Stroke, Vision Disorders, and others.
Each format has advantages and disadvantages. Use whatever method is more likely to result in your treating doctor completing a detailed report about what you can and cannot do – and why.
When is the Best Time to Ask for a Disability Opinion from a Doctor?
I recommend asking any treating doctor that you trust to complete two disability letters and reports.
Ask for one as soon as you apply for disability or soon after.
And ask for an updated medical opinion on disability when you find out your disability hearing date (if the SSA denies your initial application and request for reconsideration).
Presenting two medical opinions months (or years) apart can help you prove that your condition has worsened – and how and why.
What Should My Doctor Put in the Disability Letter?
A specific disability report that states your restrictions and explains the reasons for your limitations is helpful in your Social Security Disability claim.
A short disability letter stating that you are permanently disabled and unable to work is not. In most cases the Social Security Administration will ignore that type of letter or give it little weight. This is because the SSA decides if you meet the Social Security Act’s definition of disability – not your physician.
Your doctor’s disability letter must go further and give more detail.
Code of Federal Regulations Section 404.1513(a)(2) defines the term “medical opinion” and is a starting point for the information your physician’s disability report should include:
- Your medical diagnosis
- When the doctor first diagnosed you with each medical condition or injury
- The clinical evidence (objective, subjective, diagnostic imaging such as MRIs, CT scans, and electrodiagnostic studies, etc.) supporting the doctor’s diagnosis and opinion
- What treatment (pain management, surgery, conservative care, etc.) you have received and what future medical care you may require
- What symptoms you have reported, including pain, numbness, tingling, or headaches
- Your ability to perform the physical demands of work activities, such as sitting, standing, walking, lifting, pushing, pulling, carrying, or other physical functions (including reaching, handling, stooping, crouching, crawling, or bending)
- Your ability to perform the mental demands of work activities, such as understanding, remembering, concentrating, maintaining pace or persistence, regularly attending, carrying out instructions, or responding appropriately to supervision, co-workers, customers, or other work pressures.
- Your ability to perform other work demands, such as seeing, hearing, or using your sense of smell
- Your ability to work in specific environmental conditions, such as extreme temperatures or around chemicals, gases, or fumes
- Whether you may have side effects from the medication prescribed for your health impairments
- Your prognosis – whether your medical condition and functional abilities will improve, worsen, or stay the same with time.
Can My Attorney or I Draft the Medical Opinion for My Doctor?
No.
You can talk with your medical providers and help them draft the medical opinion. This assistance includes explaining the Social Security Disability system, providing additional evidence such as reports from other health care providers, and giving an overview of what the disability examiner might find important.
But do not tell the doctor what to say.
Should I Ask All My Doctors for Letters Supporting My Disability Claim?
No.
Do not ask a treating physician to give a written report discussing disability and what you can do unless you think the doctor will support your claim.
The SSA’s evidence rules and regulations require you to submit or inform the SSA about all evidence known to you regarding whether or not you are disabled. And the rules state that evidence includes not only objective medical evidence but also medical opinion evidence. This means you must submit a doctor’s letter if it hurts your case.
The SSA even requires you to submit a doctor’s negative or neutral opinion statement if you later convince the doctor to change the opinion and provide a more supportive letter.
These evidence rules are why I never recommend asking a doctor to write a disability report unless you have a good idea of what the doctor will say.
Do Doctors Have to Fill Out Disability Forms?
No.
A doctor can refuse to complete disability paperwork.
If My Doctor Writes a Letter Saying I am Disabled and Completes a Detailed Report, Will My Social Security Disability Claim be Approved Automatically?
No.
But you have a much higher likelihood of winning your case than if you did not have a support letter.
A detailed disability report from a physician that has examined and treated you multiple times is the most critical piece of evidence you can present to the SSA.
Why Does My Doctor Refuse to Fill Out Disability Forms?
Your doctor may refuse to complete Social Security Disability forms or attending physician reports for several reasons. These reasons may include:
- Your doctor has had a bad experience with litigation and does not understand that the Social Security Disability system is non-adversarial.
- Your doctor does not believe you are disabled. The doctor may think you can work full duty. Or may not understand that you can receive disability benefits even if you can perform light duty.
- Your doctor does not have the time to complete the forms. In my experience this problem is more common with specialists such as orthopedic surgeons than with primary care physicians and psychiatrists. Make sure you ask the doctor to complete a disability letter several months before the scheduled hearing and then follow up often.
- Your doctor is not familiar enough with your condition and thinks it is too early to discuss your abilities. Asking a physician to write a disability letter at your first visit is usually a mistake. It is essential to develop a relationship with a medical provider before asking them to get involved in a personal injury or disability case.
- You have not paid the proper fee. Many doctors charge a fee for completing disability paperwork because it reduces the time they can treat patients. I offer to pay a fee when asking the doctor to complete disability forms.
What Can I Do if My Doctor Refuses to Fill Out Disability Paperwork?
The first step you should take when a doctor refuses to complete disability forms is to determine why.
For example, if your doctor does not believe you are disabled, you should not ask that doctor to write their opinions.
However, you have several options to persuade the doctor to help you win your disability claim if the problem is the doctor’s lack of time or familiarity with the court system. Or just an unwillingness to get involved. These options include:
- Ask your doctor to refer you to another physician or physical therapist specializing in functional capacity evaluations (FCEs) and permanent impairment ratings. An FCE test lasts three to eight hours and assesses your ability to perform specific workplace activities. An impairment rating determines your percentage loss of use of the injured body part under the American Medical Association’s (AMA’s) Guides to the Evaluation of Permanent Impairment. Some examiners will even provide whole body impairment ratings.
- Ask your doctor to speak with your attorney.
- Change your treating physicians. Finding a new doctor is inconvenient. And there is no guarantee that a different doctor will find that you are disabled and write a supportive letter or complete Social Security Disability forms. But you have a lot at stake with your SSDI or SSI claim. And your Social Security lawyer may be able to refer you for treatment by a doctor known to complete detailed disability reports and help with litigation.
An Experienced Disability Lawyer to Help You Gather Evidence and Present Your Case
If you are overwhelmed by the disability process or the Social Security Administration has denied your SSDI or SSI claim, call us for help: (804) 251-1620 or (757) 810-5614.
My firm has helped thousands of clients with Social Security Disability claims. We understand the importance of doctor disability letters and what they need to say, and we will present your case in the strongest way possible.
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