INFORMATION: MEDICAL RECORDS AND SSA DISABILITY FORMS

The initial information SSA uses to adjudicate a claim is generally acquired through the medical record, SSA disability application forms, and supplemental documents submitted by health professionals. Although most information used at the Listings Step is found in the medical record, this information is not always complete or of high enough quality to adequately make a determination. The medical record is developed by health professionals primarily to follow a person’s health history, not extent of disability, but the poor quality of record keeping is part of the problem. As a result, SSA must use more resources to seek additional information. Many Disability Determination Services have developed forms specifically to supplement HIV claims so that disability examiners and medical consultants have adequate information at the beginning of a decision process, saving time and resources. This reflects a need for SSA’s application forms to be updated.

The committee expects that the forms will be updated to reflect revisions to the Listings and include measures of impairment, disability, and functioning. The forms should also be responsive to the decision-making needs of disability examiners and medical consultants.

ACCEPTABLE SOURCES OF INFORMATION

The information that SSA uses to make its decisions often comes from a claimant’s “treating source,” which includes “acceptable medical sources” and “other sources”1 who can provide relevant information regarding a claimant’s impairment. As described in Chapter 1, “acceptable medical sources” are limited to physicians, osteopaths, optometrists, psychologists, podiatrists, and speech-language pathologists. The opinions of these clinicians are often given controlling weight over “other sources.”

“Other sources” are defined as those who can help provide supporting opinions in areas such as prognosis and physical and mental restrictions. When such sources have more meaningful and informative interactions with the claimant, these opinions receive equal weight or can outweigh those of acceptable medical sources.

Overall, SSA’s regulations and rules make it seem that the opinions of “other sources” are not as important as those of the “treating source.” Other sources may not be appropriate with respect to diagnosing HIV infec-

1

Other sources are defined by SSA to “include public and private agencies; nonmedical sources such as schools, parents and caregivers, social workers and employers; and other practitioners such as naturopaths, chiropractors, and audiologists” (http://www.ssa.gov/disability/professionals/bluebook/evidentiary.htm).



The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement