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Medical records and Social Security disability benefits

West Virginia residents who apply for disability benefits from the Social Security Administration do not need to have a past medical history. However, disability examiners tend to prefer applicants to present records that demonstrate past medical treatment. Individuals who have received treatment in the past for their disabling condition can present physician notes to provide a perspective on their conditions that may not otherwise be available.

The physician notes are important because hospital treatment notes do not usually include information about patients’ physical or mental limitations or about their responses to different treatments. The information that is provided in hospital records is generally objective medical data, such as lab tests and imaging results; hospitals also provide records of acute medical treatments. However, the hospital records do not provide disability examiners with the information need to ascertain the ongoing severity of an applicant’s disabling condition or how the applicant may be unable to work to be self-supporting because of the limitations caused by the condition.

In order to obtain SSI disability or SSDI, applicants must have an impairment that limits their ability to function to such a degree that they are unable to execute normal daily activities, such as paying bills, shopping, working, driving or doing household chores. Past medical records can give disability examiners a long-term view of how debilitating an applicant’s medical impairment has been.

Some of the information that disability examiners look for in medical records includes unbiased medical proof that verifies an applicant’s assertion of a mental or physical impairment. Such proof may include breathing tests, imaging results or blood work.

An attorney who handles Social Security disability cases may assist clients through the process of applying for disability benefits and with obtaining pertinent records. Legal representation may be provided at appeal hearings for individuals whose claims have been denied.