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Find answers to frequently asked questions.

Question:
Should I file a SSI/SSDI claim when there are no medical records available?

Yes, you should file a SOAR-assisted application because even if you don’t have access to the medical evidence, DDS will request directly from prior treating sources and/or schedule appropriate Consultative Examinations (CE) to obtain diagnoses. Remember, SSA needs a diagnosis to make a disability determination. Remember, to write in the “Remarks Section” on SSA forms, about your efforts to obtain medical information so that DDS will know what they need to do to medically develop the claim.

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Question:
Some of the records I received from medical facilities are on a disc, how do you recommend submitting these to DDS? I have printed limited pages for MSR writing, but not the disc in completion.

This is a great question! While DDS does not have a way to process records received via disk, this sounds like a good opportunity to speak with them about signing up for Electronic Records Express, which allows you to upload medical records directly into an applicant’s file from your computer without having to print them. I recommend reaching out to your DDS Professional Relations Officer, or your local SOAR contact, for details on how to register.  This should be a quick process, allowing you to upload these records without delaying your current case.

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Question:
What are your recommendations if the client does not have enough medical documentation to support their illness ?

To meet SSA’s definition of disability, the applicant’s diagnosis must be documented in medical records, laboratory reports, or other clinical findings of a physician or psychologist. DDS prefers that medical evidence come from an ongoing treatment provider. If this medical documentation is not available because the applicant has not received treatment for these conditions, we recommend that SOAR practitioners try to arrange for a physician or psychologist to conduct assessments, including documenting the applicant’s diagnosis and functioning, before submitting the SSI/SSDI application.

If it is not possible to arrange an evaluation before submitting the application, DDS may arrange for a consultative exam (CE) for the applicant, including physical or psychiatric testing based on the applicant’s alleged conditions. More information about CEs can be found here. In these instances, it is especially important that the SOAR practitioner provides comprehensive information about the applicant’s impairments in functioning through the Medical Summary Report. Collateral information from caseworkers, family members, and former employers can also be helpful in supporting an application with limited medical documentation.

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Question:
When requesting medical records, what type of records are specifically needed? I requested ALL records for a client, and received over 500 pages from the hospital. In the future, can I make a more specific request for efficiency purposes?

Great question! While we do typically advise to collect all records, 500 pages is understandably a lot! Not all applicants will have this many, but if you are seeing that certain hospitals/providers tend to send significant amounts (particularly if they aren't helpful for the application), you could ask for: Inpatient hospitalization records, discharge summaries, outpatient/emergency records, and psychiatric examinations/mental status exams. Those are all pretty key for the application. When you submit the records to DDS, I'd recommend adding a note that these were all that you requested, so that it doesn't look like you just weren't sending everything you have.

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Question:
When the MSR is signed by an Acceptable Medical Source (AMS) is there any HIPAA concern if the MSR contains information from other treating providers?

An MSR that has been written based on properly released records can be shared with the primary AMS.  At the point of obtaining the signature, it is primarily a privacy issue, not HIPAA. However, it would be a best practice to have a release signed by the applicant permitting the case worker to communicate with the AMS.

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