What medical documentation is needed for a Kingsport, Tennessee Social Security disability case?

Our Mountain City and Kingsport, Tennessee disability clients often ask us what they need to collect from their doctors for their Kingsport disability case. We let them know that the Social Security Administration requires a lot of medical documentation for disability cases. And the Social Security Administration wants to see medical test results not just conclusions from your treating doctor.

Collecting medical documentation to prove you are disabled

The Social Security Administration will carefully consider your file’s medical documentation to determine whether you are disabled. To receive Tennessee disability benefits, you must be found “disabled” by the Social Security Administration. You are disabled only if your physical or mental impairment is so severe that you are unable to do your previous work and you cannot, considering your age, education, and work experience, do any other substantial gainful work that exists in the national economy.

The Social Security Administration’s determination of whether you are disabled involves a detailed analysis, but your ability to work, age, education, and recent jobs are key factors that affect the determination. This evaluation process, however, is complex and the Social Security Administration’s determinations can sometimes defy common sense.

The Social Security Administration in Kingsport, Tennessee and nationwide is likely to award you Social Security disability benefits if your answers match the ones below:

  • Do you have a job that pays you more than $1,000 per month and involves more than minimum duties? No
  • Do you have a severe impairment? An impairment or combination of impairments is severe if it significantly limits your physical or mental ability to do basic work activities. Yes
  • Will your impairment last 12 continuous months (or is it expected to last that long) or result in death? Yes
  • Does your disability meet or equal one of the impairments described in the Social Security Administration’s regulations known as the Listing of Impairments? The Listing of Impairments consists of medical findings for many common physical and mental impairments (and some that are not so common), which, if present, require that a claimant be found disabled (even without looking at whether a claimant can do his or her past relevant work). The Listings are available on the Internet at http://www.socialsecurity.gov/disability/professionals/bluebook/index.htm. If Yes, you qualify. If No
  • Considering your residual functional capacity, are you able to do your past relevant work (any work you have performed in the last 15 years, including your easiest job)? No, and…
  • Can you make an adjustment to other work that exists in significant numbers in the economy, considering your residual functional capacity, age, education, and work experience? If No, you qualify.

Medical documentation is very important in Tennessee Social Security disability cases because, for the Social Security Administration, the issue of whether your disability meets or equals one of the Listings’ impairments is one more of medical fact than medical opinion. When dealing with the Listings, the Social Security Administration regards the treating doctor mostly as a source of medical evidence. However, the Social Security Administration will not ignore a treating doctor’s opinion, and, in practice many administrative law judges will carefully consider any well-supported opinion that a claimant’s impairment meets or equals the Listings. However, the determination of whether or not a claimant meets the Listings is an issue reserved to the Social Security Administration not the treating doctor. To make these determinations, the Social Security Administration carefully considers your file’s medical documentation.

What medical documentation we obtain for your Kingsport Social Security disability claim and for all our Tennessee disability claims

Because of its importance, we work hard to obtain medical documentation for all our Social Security disability cases. The medical records we will collect will depend on our theory of the case.

Hospital records

Depending on your disability case’s theory, we will request hospital records for your case, including: admission histories and physicals; all reports by medical consultants; physical therapy evaluations and reports; surgical/operative reports; emergency room records; pathologist’s reports; and discharge summaries and test results pertaining to the claimant’s impairment, such as a lab reports, radiologist reports, nerve condition/EMG reports, and nuclear medicine reports.

The hospital records we submit to the Social Security Administration will depend on our theory for your case. For example, if you were hospitalized for an acute illness and then later released, the hospital records concerning your acute illness may be less important than the records generated after you have been stabilized. This is because the issue in most cases is whether you can work after recovering from the acute phase of an illness rather than whether you can work while hospitalized. However, if a claimant is hospitalized so often that the frequency of hospitalization is part of our theory of the case, then we would, at a minimum, obtain copies of all discharge summaries. We can also obtain a list of all admissions that is maintained by most hospitals and available by special request.

If one of our clients is a veteran, we will also obtain any hospital records from a Veterans Administration Hospital. From the VA hospital, we may need to collect VA rating exam reports and VA disability ratings. Although VA disability determinations are not binding on the Social Security Administration, they are considered evidence and they should be considered.

Other records from medical sources

Your file should have a complete list of your medical providers. We will work with you to make sure that this list is up-to-date and contains all the medical providers that appear in the medical records themselves.

For your case, we also collect copies of your medical records from various medical sources. The Social Security Administration, in Kingsport, Tennessee and nationally, classifies some medical sources as “acceptable medical sources” and others as “other” medical sources.

Acceptable medical sources include: physicians, osteopaths, podiatrists, optometrists and psychologists. “Acceptable” medical sources, such as your treating doctor, can provide information about the nature, severity, extent and duration of your impairments, including observations and opinions about how well you are able to function, the effects of any treatment, including side effects, and how long the impairments are expected to limit your ability to function.

For “acceptable” medical sources, when the examination or treatment by such healthcare provider is pertinent to your case, we will obtain copies of such provider’s notes in addition to the medical reports. In addition, for mental impairment cases, when we obtain office records from a psychologist we also request copies of all test results, as required by the mental impairment Listings.

Medical sources that are not on the list of “acceptable medical sources” include: chiropractors, physical and occupational therapists, nurse-practitioners, physicians’ assistants, audiologists and therapists. These sources are on the Social Security Administration’s list of “other” medical sources; and they are limited to showing “the severity of your impairment(s) and how it affects your ability to work.”

Medical documentation from non-medical sources

In addition to the above medical sources, we also sometimes obtain medical documentation from the following non-medical sources, depending on the theory of your case:

  • Pharmacy records from pharmacies, which, among other things, can underscore testimony about a claimant’s frequency of taking medications;
  • Medical records from insurance companies;
  • Former employers’ records, including attendance records, performance evaluations, and records explaining reasons for a claimant’s termination/medical leave;
  • Vocational rehabilitation agencies’ records, including all vocational evaluation reports and results of all medical and psychological evaluations done at the request of the agency;
  • Arrest and conviction records (for some mental impairment cases); and
  • Social welfare agencies’ records, including forms for medical exemption from welfare work programs, assessment by disabled housing programs, and observations in social workers’ notes.

Less helpful medical documentation

Not all your medical documentation is useful in a disability case. For example, records concerning routine medical care for matters having nothing to do with your disability (such as gynecological records), or records from more than a year before the alleged onset date (except in cases where the impairment is a slowly progressing impairment and/or a worsening episodic impairment) are not considered helpful as they seldom add anything to a case.

But in some disability cases we will need to obtain absolutely every piece of medical evidence that exists. For example, if a claimant has an impairment such as chronic fatigue or fibromyalgia, we will need to prove that he or she is disabled by an impairment that has few objective signs or the claimant will lose. In these cases, we collect all the medical records, including treatment records and records with the claimant’s statements about daily living and work activities. For every record included in the file, we will explain how it relates to our theory of the case.

Key medical documentation to be included in your file

We will make sure that your case file contains the actual test results for all significant positive tests, and that those results are consistent with the Social Security Administration’s specific requirements for particular kinds of medical evidence. For example, for a cardiac case, copies of the electrocardiogram tracings are required by the Social Security Administration in addition to the cardiologist’s interpretation of them.

If negative records exist in your case, we will also submit those and will refine our case theory to account for the existence of such records.

Experienced Tennessee Social Security disability lawyers available for your Tennessee or Southeast disability case

As experienced Tennessee disability attorneys, we make sure that the files of our disability claimants throughout the Southeast contain all the relevant medical evidence for their case. And we use such medical documentation to uncover and present our clients’ strongest disability claim to the Social Security Administration.

If you want our assistance with your claim, give us a brief description of your situation using the form to the right. Or contact us at:

Smith and Cockett
Tennessee disability attorneys
E-mail us

Mountain City office:
247 West Main Street
Mountain City, Tennessee 37683
Local: 423-727-7913
Toll-free: 877-302-8665

Kingsport office:
224 Colonial Heights Road
Kingsport, Tennessee 37663
Local: 423-392-0100
Toll-free: 877-302-8665

Serving the legal needs of Tennessee disability claimants – and disability claimants throughout the Southeast – since 1976