– Why Complete a Medical Assessment on Behalf of Your Patient?

In Social Security cases, the treating physician opinion is given great weight and in LTD Insurance Policy cases it is examined very carefully by non-treating, non-examining peer reviewers to assess a patient’s credibility.

Treating Physician’s Opinion. We know your time is valuable and it cannot always extend to writing letters and filling out forms on behalf of patients.  We are willing to advance the costs on behalf of your patient for your time to complete detailed medical assessments forms and narrative reports.  We are also willing to make our phone dictation service available for you to call in and dictate your narrative report to be emailed to you for your review and signature.  Short, cursory statements (example: “My patient is 100% disabled and unable to work”) are usually of no benefit. A Judge will give little weight to a physician’s medical opinion if that opinion cannot be demonstrated to be supported by objective medical findings and treatment notes.

– What should be included in the Medical Assessment?

A medical assessment that is well supported by objective evidence and detailed treatment notes confirming both the diagnosis and the claimant’s symptoms is important.

Details of the Medical Assessment.  Ideally, a statement from a doctor should be detailed and based, as much as possible, on objective testing and physical examination.  To support your patient’s complaints of pain or other subjective symptoms a doctor should confirm the severity and frequency of the symptoms and provide (1) evidence of an underlying medical condition and either (2) objective medical evidence confirming the severity of the alleged pain (or other symptom) arising from that condition or (3) that the objectively determined medical condition is of such a severity that it can reasonably be expected to cause the alleged pain (or other symptom).

A narrative should be well supported as well as advocative. The statement should, in most cases, mirror the RFC form (Residual Functional Capacity form) used by physicians and examiners at Disability Determination Services to make decisions on cases.  If there are particular symptoms that result in exertional or non-exertional restrictions or limitations these should be addressed.  Additionally, if your patient’s medical condition is so severe as to be per se disabling under a “Listed Impairment” this should be addressed as well.

Link to Physical RFC forms

Link to Mental RFC and Listings form

Link to Cardiac RFC and Listings form

Link to Multiple Sclerosis RFC and Listings form

Link to Lupus RFC and Listings form

Link to Traumatic Brain Injury RFC and Listing form

Many other Impairment Specific Form are available.  Please ask us!

Link to the Listing of Impairments for Medical Professionals


Therefore, a letter or statement from a treating doctor should point out the following:

1. A patient’s diagnosis or diagnoses.

2. The objective evidence supporting the diagnosis.

3. Whether or not the patient’s condition meets the requirements of a listed impairment or in your expert medical opinion is the equivalent of a listed impairment if all the conditions are not met.

4. A patient’s physical restrictions (e.g. level of inability to sit, stand, walk, stoop, crouch, grasp, reach, or otherwise move)

5. A patient’s non-exertional restrictions (e.g. impairments not related to strength – including maintaining position, using fingers/hands/arms, seeing, hearing, frequent urination, mental functioning, and tolerating environmental working condition such as dust, fume, irritants, noise, cold, heat, etc…)

6. The credibility of the patient’s subjective symptoms

7. A claimant’s prognosis.

8. Whether the patient is unable to sustain full-time, competitive employment – 8 hours/day, 5 days/week, 50 (50/52) weeks a year [adhere to a schedule without an unreasonable number of absences (more than 2 per month) or excessive breaks or lapses in basic attention and concentration]

Answers to some Frequently Asked Questions about the Treating Phyisican’s Medical Assessment

Why does a patient need the opinion of a treating doctor in making a social security disability claim?   The treating doctor brings a unique perspective to the medical evidence that cannot be obtained from the objective medical findings alone or from reports of individual examinations.

What information does SSA need from the treating doctor?  A complete copy of the patient’s medical records.  The nature, severity, extent and duration of a patient’s impairments, including observations and opinions about how well the patient is able to function.

To decide if claimed limitations are reasonable for a particular patient, should I consider whether the average person with the same impairment would be so impaired?  No. SSA’s rules recognize that an “average man” test is not appropriate. SSA acknowledges that symptoms limit some people more than they do others.

Should I refer the patient for a functional capacity evaluation?  If it is the only method you have of assessing your patient, but it is not necessary.  SSA itself never asks a claimant to undergo a functional capacity evaluation. As a rule, functional capacity evaluations, which last at most only a few hours, do not reliably answer the essential question: What is your patient’s capacity to sustain work activities eight hours per day, five days per week, fifty weeks per year?  The treating physician is usually in the best position to determine how long a client can sit, stand, walk, etc…in an eight hour day on a consistent basis.

Doesn’t a doctor need special expertise to estimate a patient’s capacity for performing work-related activities?  No. SSA says that a treating doctor who has developed a longitudinal perspective on a patient’s problems is in a position to make a valuable contribution to determining whether a patient is or is not disabled. It depends on the case, of course, but usually a treating doctor who has treated a patient for a long time can provide a more valuable opinion than a specialist who sees the patient only once.

How important are objective medical findings?  Objective medical findings are very important. Such findings, in effect, determine the range of possibilities. But, as a rule, one cannot determine a claimant’s capacity for working by looking only at the medical findings for a claimant whose impairment does not meet the Listing of Impairments.

How does SSA determine whether drug addiction or alcoholism is “material”?  The test is this: If hypothetically the claimant were to stop abusing drugs or alcohol, would the claimant’s ability to work be restored?

Sometimes an answer to a question on a form is “it depends.” How can I convey this?  Explain it in the margins. The more information SSA has, the better. Some experts believe that no residual functional capacity form is ever complete without things written in the margins. SSA says that the better the explanation a doctor provides, the more weight SSA will give that opinion.

What is the worst thing a doctor can do when completing a disability form describing a patient’s capacity for work?  Describing a patient as more disabled than he or she actually is can be the most harmful especially if the medical records support an alternative picture. It is worse than erring in the other direction because it tends to make the doctor’s opinion useless for determining whether the patient meets the requirements of the Social Security Act to be found disabled.