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Medical Records and why they matter in a Social Security Disability Claim (1)

Medical Records and Why they matter in a Social Security Claim

Your medical records are a vital part of your disability claim. Without them, you have nothing! I mean, NOTHING.

In part 1 of the 15 reasons people get denied disability, we talked about how 90% of cases are denied “just because… ” (well, they kinda hope you give up and go away)

Today we will talk about a very interesting reason people get denied.

I say interesting not because it’s interesting to see people getting denied. The reason I say interesting is because it is surprising how many people don’t know how important their medical records are when they are applying for disability.

I get calls every day from people wanting to apply and when I ask them what kind of treatment they are getting they say: “I haven’t seen a doctor in 3 years”! That means this person’s records are at least 3 years old! That’s a huge gap in treatment!

Now, here’s my question: If you are not treating, how do you know you are disabled?

What if your condition is treatable and the treatment can get you back to normal? And if it’s disabling, how do we know how disabling your condition is if you are not seeing a doctor?

I also get claimants whose doctors have given up or they said: “there’s not much we can do for you”. The claimant then gave up treatment because of those words and threw their hand in the air.

Doctors Are Wrong All The Time

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The good news is that science gets better all the time. There is always a treatment, there is always something that can be done to alleviate symptoms. Either coping mechanisms, therapy, etc.

For example, we are now learning that there is actually a cure for Hepatitis C. This was not available just a few years ago. How cool is that?!

Even in those situations where the doctor said “nothing can be done anymore“, claimants should still find some kind of treatment such as pain management, aqua therapy, some maintenance appointments at least.

And if your condition is one that there is really nothing you doctor can do for you other than maintaining it (pain management, therapy), you should get a letter from that doctor so he can explain to Social Security why there is nothing he can do for you.

What you can’t do is not see a doctor for a long period of time and expect that Social Security awards your case. Here is a big secret about that:

Social Security Sees No Treatment as Improvement

In other words, they think that if you are not going to the doctor your condition is “not that bad“! Simple as that!

Here’s another kicker:

Diagnosis alone does not win disability cases


Diagnosis alone will not win cases

The biggest mistake claimants make is thinking that just because they received a diagnosis they can win a disability claim. Wrong!

Diagnosis is only the beginning. People have heart attacks and go back to work. People have cancer and go back to work. These are very serious diagnoses but with the right treatment and time, a lot of people are able to go back to work.

And remember, some claimants may not be able to do the work they used to do but they may be able to do something else. We talk a little bit more about this in our post about canned denial letters.

That’s why medical records are so important. Once you receive a serious diagnosis, the next step is treatment: Treatment will generate more medical records. More medical records generate a big picture of how disabled you are.

Medical treatment equals more medical records

What exactly are medical records?

I’m sure you know what they are, but sometimes I get people who don’t know the difference, so here it goes:

Medical records are doctor’s notes, reports from tests, lab results and anything that has to do with your medical treatment.

Every time you go to a doctor’s appointment your doctor usually takes notes of all his findings. He will also note your complaints during his examination. It is those notes that are so important. Every time you get a CT or a Xray, the clinic generates a report and a film. The notes and reports are what Social Security is looking for.


Medical Records versus Patient Instructions

Now sometimes, you go to a hospital and the hospital will give you these sheets containing information about your diagnosis. You also get a list of things you should or shouldn’t do after being discharged from the hospital. Those ARE NOT medical records.

They are called patient instructions.

They can be submitted with the records when you file your case. But they are not very useful for your claim. A lot of people get those two confused and a lot of claimants submit these as evidence of disability. Like I said before, they don’t help that much, if at all.

Gathering Medical Records

What I want you to do from now on is this: every time you go to the doctor or every so many months of visits, ask for a copy of your records.

In my State (Arizona), people are legally entitled to a copy of their medical records (please check your jurisdiction).

There is an exception for mental patients who are a danger to themselves or others. In these cases, doctor’s fear the person may harm herself if they see what the notes say. Doctors may only release them to a trusted family member and for a particular purpose (like hiring an attorney or a new doctor). Either way, you should ask for them.

The reason I’m suggesting that you ask for your records is simple: While Social Security will order medical records in the EARLY stages of your case, they will not share them with you or your attorney at that stage.

Most attorneys will ask to see your records BEFORE they decide if they will take your case. The reason is mostly because attorneys need to see if you are getting the right treatment and whether your records show that you are disabled before taking your case.

Without seeing these records, it is very difficult for an attorney to assess your chances at winning your claim.

The only time Social Security will share a copy of your medical records is when your case is on the hearing track

Even then, you will need to request those records before an attorney decides to represent you since they only release these records to the attorney of record (i.e. after the attorney decided to represent you).

To Recap:

  1. Medical Records are key for the success of your claim;
  2. Treatment is a generator of medical records;
  3. Social Security thinks if you are not seeing a doctor your condition is “not as bad” as you say;
  4. Ask your doctor for copies of your medical records to keep track of your treatment.

Books By Realtactics4DisabilityClaims

Learn the ins and outs of filing your Social Security Disability Claim with Real Tactics For Filing Your Disability Claim. This book was written by Yours Truly and it was created for those claimants who wish to learn more about the process in language they can understand.

You will also learn how to read your medical records so you can see if they are supporting your claim, and learn how to organize your file so you never lose track of your treatment.

Finally, I offer an exclusive Facebook group just for the book where you can ask questions about the concepts you learned in the book.

My book is available on Amazon Kindle and paperback. Simply click on the image below and grab your copy today!


10 best book about filing for social security disability

Buy Your Copy Here button real tactics for filing your disability claim bok (2)

Courses by Realtactics4disabilityclaims.com

You just learned why Medical records are vital to your claim, but do you know how to read them to see if they are actually supporting your disability?

Learn how to read and how to improve your medical records like a pro with my new course “Medical Records Reading 101 for Disability Claimants”. Stop wasting time “hoping for the best” with your current records. The course also includes a Checklist and Worksheet so you can keep track of your treatment to make sure you don’t have any “gaps” that could jeopardize your claim. Take a quick “free sneak peek” before you purchase the course and learn the ins and outs of improving your medical records with actionable instructions from Yours Truly (Yes, Me!).


Copy of Medical Records Reading for Disability Claimants Banner Course Card for site


If you were denied disability and you are looking to appeal with “better” evidence, I created a course about using a Residual Functional Capacity Report to add to your medical records. This is a form you can take to your doctor to complete in support of your claim. The course includes forms for physical or mental impairments and instructions on how to ask your doctor to complete them. You can take a “free sneak peek” to see if this course is for you. Click on the image below and you will be directed to the course page:

course card RFC Intro Doc buy button (1)


Also, if you are looking to file for disability and don’t know where to start, I created a course called the “5 Day File your Disability Claim” Guide where I teach you every step you should take to file your claim.

Simply click on the image below and it will take you directly to the course page. Take a “free sneak peek” of the first lesson to see if this course is for you.

You know the blog, now you can take one step further and learn the process of preparing and filing your claim.


5 Day File Your Disability Claim Course


Please share this post with anyone you think could benefit from it.

Also, don’t forget to sign up for our email updates (below) to get valuable information for your claim. You can also follow me on Facebook and Pinterest for the lasted news and posts.

In the next post, we will talk about how to order medical records and save money in the long run.

Until next time,

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  1. Liz Wilcox says:

    Wow! I learned so much in just a few short minutes. My mom has been trying for years to get on disability. She has an array of problems, mostly mental. I definitely need to share this information with her. Thank you so much!

    • Tatiana says:

      Thank you for reading! Glad I was able to help. If you have any questions feel free to contact me through email or FB message so I can give you some extra guidance. You can also sign up for email updates since I try to post at least every 2 weeks.

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