Your medical record is the biggest factor in determining the ultimate result of your social security disability case. No, it’s not the only factor, but its importance cannot be overstated. And although collecting medical evidence may sound simple, it is something that is often overlooked and taken for granted by claimants. One of the most common statements I hear from my new clients during their initial phone call is something like, “I got denied, and social security didn’t even contact my doctor!”

If the government diligently sought out the entire medical history of every one of the tens of thousands of disability claimants, put those records into the official file, and asked for medical opinions from treating physicians, there would probably not be a need for lawyers in these cases. However, this is not always the case, and a big part of the job of a lawyer is to make sure the record is complete by the time the case is set for hearing.

Here are a few helpful tips to keep in mind when collecting medical evidence for your disability case.

Don’t trust the government

“If the government did it, it must have been done right” . . . said nobody ever.

Too many people think they can just sit back and let the government do all the work of collecting their medical records, and then in a few weeks the checks will magically start appearing. That is typically not how it works. Claimants for social security disability benefits are allowed to collect their own records and send them to the Social Security Administration for inclusion in their case file. Being proactive ensures that the judge will have all of the evidence necessary to reach a fair decision.

But if done incorrectly, don’t be surprised if you receive a denial letter that shows a list of received medical records that omits things such as your doctor from five years ago, a one time hospitalization, your chiropractor, out of state records, or the records of a doctor who has changed locations.

Missing records can leave the official file incomplete and may lead the judge to think that your condition is not as serious as you claim. A complete record of your diagnosis, treatment, and medications will allow the judge to have the correct picture of your medical problems over the course of your life. If an incomplete record makes it appear that you have had treatment only sporadically, have never been hospitalized, or have not been to a specialist, it is very possible the judge will not view your condition as serious and will deny your claim.

In Nebraska, medical providers must give you your records and cannot charge you any money for copies, staff time, or postage. If you do not know the address of your local social security office, you can look it up on the Social Security Administration’s web site. Make sure your records are sent to the right place, and follow up to make sure they have been received.

Communicate with your providers

As you might imagine, doctors don’t really like to give things away for free, so simply asking for your records will likely result in you getting a bill from your doctor. When you request records from a doctor or hospital, you need to let them know that you are pursuing a disability claim and that under Nebraska law they cannot charge you for producing your file. Medical records custodians usually know this, but a little reminder doesn’t hurt. If you want your records sent directly to the Social Security Administration, you will probably have to sign a release. The government usually sends claimants a release to sign but you may want to double check with your provider to make sure they have a release on file so the records can be sent in a timely manner.

Under federal regulations, doctors who treat you can give opinions about your functioning and your ability to work, and some doctors are willing to write letters on behalf of their patients. These letters can make the difference between the judge approving your claim and the judge giving your case a thumbs down. Making a phone call to the doctor and reminding the staff that you are a real person can convince your doctor to take a few minutes out of a busy day and write a letter about your medical condition.

Deadlines, deadlines, deadlines!

As with other types of court proceedings, there is a time frame in which you must act. One of the reasons you should consider hiring a lawyer is that there are rules governing the admission of medical records as exhibits, and one of those rules is the time frame for sending in records. If you do not get your records to the disability examiner before a decision is made, your claim will be decided without all of the evidence relevant to your case. So make sure to get your records to the Social Security office in time if you want the disability examiner to consider them early in the claims process.

If your claim is denied by the disability examiner at the initial application and reconsideration stages of the claims process, you will have to file a request for a hearing before a judge. That stage of the process typically takes 15 to 18 months.

All medical evidence that you want the judge to consider must be sent in at least five days prior to the hearing. The judge may allow your record to remain open after the hearing, if you’re able to provide a good reason, but even though you can send your records in near the time of the hearing or sometimes even afterwards, it is in your best interest to get the records to the judge as soon as possible so that when the judge reviews the file in the weeks leading up to the hearing, they will have a good idea of your condition and why you cannot work.

Help! My doctor won’t cooperate!

Sometimes I run into doctors who, for whatever reason, will not send in the medical records. I have a form letter that I send to the doctor’s office that reminds the employees that they are required by law to provide the records at no charge, citing the law which requires them to do so at no cost. If that doesn’t do the trick, a follow-up phone call by my medical records specialist usually gets the records.

However, sometimes we are still unable to retrieve the treatment records and notes. In those rare circumstances, we write a letter to the judge asking that a subpoena be sent from the federal government that orders the doctor to turn over the records. Federal regulations allow judges to issue subpoenas upon the request of the claimant. Subpoenas are only issued in circumstances when routine requests for records have failed. Therefore, as stated previously, it is important for you to be able to show to the judge that you have tried, with a letter and a phone call, to obtain the records prior to requesting a subpoena.

Team work makes the dream work!

When you make the decision to hire an attorney, you are joining a team of trained, experienced professionals who are experts at getting medical records and providing them to judges. If I could make one wish with new clients, it would be that they come to my office with a complete list of the names and addresses of all medical providers, current and past. Giving your lawyer a ready-made list puts you at the top of the “favorite client” list and makes it easy to get a medical file put together quickly for review.

Also, keep in mind that when you change medical providers, have a follow up visit with your doctor, make an emergency trip to the hospital, or get referred to a specialist, let your lawyer know this information as soon as possible, and no later than one week before the hearing. This allows us to communicate with your medical providers and get the opinions and documentation we need to win your case.

With due diligence, good communication, and a little help from your doctor’s office, we can work together to prepare your case for a hearing in front of a judge and get a successful outcome!