FAQ

Mental health treatment records are a necessary and integral part of the evidence needed for DDS to make a disability determination for someone alleging mental illness as an impairment. You are permitted and encouraged to support a claimant’s application with the disclosure of your records (with proper authorization). The records that are excluded from this authorization are “psychotherapy notes,” which are a specific type of note not typically a part of most medical records, especially in publicly funded settings.

As HIPAA defines the term, “psychotherapy notes means notes recorded in any medium by a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of the individual’s medical record. Excluded from “psychotherapy notes” are medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date.

If you keep psychotherapy notes separate from your other medical records, you can send the set of records without the psychotherapy notes. If you do not keep psychotherapy notes separate from other parts of the medical records, you can legally disclose all of the records. However, you can choose to black out or remove the parts of the records that would be considered psychotherapy notes. Another option is to prepare a report that details the critical current and historical aspects of the applicant’s treatment and functional information, such as a SOAR Medical Summary Report.

For more information, see SSA’s Fact Sheet for Mental Health Care Professionals.

Generally speaking, medical providers are not legally bound to provide records to a third party. They are not required to provide records to DDS, either. However, HIPAA regulations require healthcare providers to provide individuals copies of their own records: 

"The Privacy Rule generally requires HIPAA covered entities (health plans and most health care providers) to provide individuals, upon request, with access to the protected health information (PHI) about them in one or more “designated record sets” maintained by or for the covered entity.”

We hear from most SOAR providers that they are able to get medical records from most sources. Some states have special laws that cover access to records for disability applications. We also do our best to build relationships with commonly used providers and the medical records departments to try to improve those relationships, and clarify and expedite processes.

As the claimant’s representative (using the SSA-1696 Appointment of Representative Form), you can request a copy of the claimant’s previous and current files, which include the medical records SSA and DDS received with the application. These documents are generally provided on a CD. This is allowed under the Privacy Act (5 USC § 552a (b)) “An individual may give SSA written consent to disclose his/her personal information to a third party of his/her choosing.”

Note: When using the SOAR process, staff will want to collect the medical records and submit them to DDS rather than the other way around. The reason for this is to ensure that the DDS receives all pertinent information. However, obtaining a CD from DDS can be useful when you assist an individual who has already applied and been denied.
Source: https://secure.ssa.gov/poms.NSF/lnx/0203305001

At the hearing level, many Administrative Law Judges (ALJs) will invoke ‘Rule 3.7: Lawyer/Advocate as Witness’.  Under the advocate-witness rule, you cannot serve as both advocate (via the SSA-1696) and witness.  The ‘witness’ is required to testify on the basis of personal knowledge, while an advocate is expected to explain and comment on evidence given by others. This dual role can give rise to a conflict of interest.

In your case, the ALJ viewed the 3^rd Party Function Report you completed as ‘providing witness testimony’ which can prejudice the ALJ’s decision. Often, the ALJ will recognize that the SOAR case worker is not familiar with this rule, and educate them on their options.  When there is other evidence in the file and the SOAR case worker does not need to testify themselves, they will remain the official 1696 representative. By doing so, they are able to cross examine expert witnesses and directly examine the applicant (i.e. ask them questions in front of the judge during the hearing).

Not really.  There are many reasons for this.  Firstly, hearings are tape recorded and physical movements won’t show up on audio.  As well, any physical limitations that are the basis of a disability claim must have medical records to back it up, not just an ALJ’s observations. Courts have discounted “sit and squirm” opinions from ALJs who “eyeball” the client, and say they have no back problems, for example, because they sit in a hearing for two hours in no obvious discomfort.  DDS is supposed to consider the claimant’s capacity to perform work activities on a sustained basis, not just on what they can or cannot do on a one-time basis.  (See Social Security Rulings 96-8p and 96-9p) https://www.ssa.gov/OP_Home/rulings/rulfind1.html#YRT1996)

To help expedite a hearing, the applicant or their representative can submit a letter of "dire need" to the Office of Hearing Operations (OHO).  The letter should describe the applicant's conditions, how they have worsened since the reconsideration was filed, and why they will worsen still if they are not granted an expedited hearing. You need to explain how the applicant is unable to get shelter, medical care, and/or food. Be as specific as possible and provide examples of the applicant's functional impairment.  If you can reference medical records, that is very helpful. There is no guarantee that the administrative law judge will grant an expedited hearing, but it is worth trying.

Occasionally elected officials will send a form letter (a dire need letter of sorts) to OHO to inquire about the claim and to ask for an expedited process.  

If the case is pending at the initial or reconsideration stage, you can become the applicant's representative via submission of the SSA-1696: Appointment of Representative form. You will then be able to communicate with SSA/DDS about the application and request access to the materials that have been submitted. After reviewing the person’s file, you'll know what needs to be addressed, just as when you are starting anew with someone. If the person isn't willing to have you be the representative, ask if they have one - if so, try to assist that person with what needs to be addressed.

If the person is waiting for an appeal hearing, it may be necessary for you to secure legal representation for them through agencies such as the state Protection and Advocacy organization, Legal Services, Legal Aid, or another kind of pro-bono legal service.

Read more at Prior or Pending Applications.

You can obtain valuable insight into the reason an applicant was previously denied by reviewing the applicant’s electronic folder, or at minimum, obtaining the “Disability Determination Explanation” or denial notice. Most likely, you will have easy access to the denial notice from the applicant or, if you are the authorized representative, SSA should have mailed a copy to you. You can also request reason for denial by contacting your local SSA office. Learn more at Reviewing Denial Notices.

HIPAA requires medical providers to release the patient's records within 30 days after the request is received (https://www.hhs.gov/hipaa/for-professionals/privacy/guidance/access/ind…). Some states have laws that require the release of medical records in fewer than 30 days.

RFC forms are very useful and can be a vehicle for the treating source to provide medical opinion evidence, forcing the ALJ to consider it.  Sometimes the ALJ will discount the RFC form if he/she feels that it is not supported by the medical records.  For instance, sometimes a doctor will give the opinion that the applicant “can sit for 30 minutes” but nowhere in the medical record is there anything about this at patient appointments. So, be aware of that.  Also, be sure that the answers on the form are internally consistent. 

For the second question, once DDS determines the applicant has met a Listing (at Step 3 of the Sequential Evaluation), DDS stops developing the claim for other impairments.  DDS looks at the applicant’s RFC at Step 4 and Step 5.  The applicant’s RFC is determined and compared to the physical and mental demands of the past relevant work (Step 4). When it is determined that the applicant cannot perform past relevant work, RFC, age, education and past work experience must be considered to determine if there is other less demanding work the applicant can do.

Finally, RFC forms which are designed with space for the physician to provide their medical opinion, and not merely a form with check off boxes, is most effective.