Medical records are important to prove disability

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When applying for Social Security Disability Insurance, medical records are vital in proving that you have a recognized disability, or the symptoms of it, that is, or will, prevent you from working for at least a year.

“Without medical records, it becomes very difficult to substantiate your claim,” said Attorney Mallary Scheer.

Medical records from your hospital, medical provider and/or primary care physician must date back to your initial injury or illness. Records that establish a mental or physical disability are:

  1. Description of your symptoms
  2. Official diagnosis and/or clinical findings
  3. Objective test results
  4. Treatment (past and current)
  5. Proof that your diagnosis hinders the ability to work
  6. Any additional documentation you believe is relevant

Many of Mallary’s Social Security clients have limited access to medical care providers because of their current lack of employment due to their disability or lack of health insurance.

“This puts those in need of disability between a rock and a hard place. You can’t get the treatment without Medicare/Medicaid, but you can’t get Medicare/Medicaid without the medical records to support your claim,” said Mallary.

When this happens, Mallary connects clients to free or sliding scale health clinics or faith-based services that may be willing to help.

Because it is the claimant’s responsibility to prove to the Social Security Administration that he or she is experiencing a medically determinable impairment, making sure the correct information gets into medical records is important.

When asked how one does this, Mallary explained, “I advise all of my clients to keep a log, journal or notepad and write down on a weekly basis the issues they experienced including difficulty walking or sitting, fatigue, malaise, headaches or migraines, bouts of depression, anxiety or whatever was hurting them.”

She added, “I then advise my clients to take that information with them to the doctor and either tell the doctor or be prepared to hand over the information directly to the doctor. This helps to ensure that the doctor sees the whole picture of what they are experiencing. I find without a journal, many clients forget how many bad days they had and tend to only focus on the good days when speaking with their doctor.”

For more information regarding medical records and the Social Security disability process, or if you need legal assistance, schedule a free consultation with Mallary L. Scheer Attorney at Law today.