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Form Approved OMB No. 09600662 SOCIAL SECURITY ADMINISTRATION OFFICE OF DISABILITY ADJUDICATION AND REVIEW MEDICAL SOURCE STATEMENT OF ABILITY TO DO CORRELATED ACTIVITIES (PHYSICAL) SOCIAL SECURITY
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How to fill out medical source statement example

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To fill out a medical source statement example, follow these steps:

01
Gather all relevant medical records and any supporting documents that may be necessary for completing the statement.
02
Review the form carefully, paying attention to the specific information being requested in each section. Familiarize yourself with the terminology and format used in the statement.
03
Begin filling out the statement by providing accurate and detailed information about the patient's medical condition or history in the designated sections.
04
Use clear and concise language when describing symptoms, diagnoses, treatments, and any limitations or restrictions imposed by the medical condition.
05
Include specific medical findings, such as diagnostic test results or clinical observations, to support the information provided.
06
If applicable, provide information about the duration of the medical condition and any expected changes or prognosis.
07
Make sure to sign and date the completed statement, and provide any additional contact information if required.
08
Keep a copy of the completed statement for your records before submitting it to the appropriate party.

Who needs a medical source statement example:

01
Healthcare professionals or medical practitioners who are responsible for evaluating a patient's medical condition and need guidance on how to accurately document it.
02
Insurance companies or government agencies that require comprehensive medical information to assess an individual's eligibility for benefits or disability claims.
03
Legal professionals who may need a medical source statement as evidence in a legal case or to support a client's claim for compensation or disability benefits.
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A medical source statement is an official statement from a healthcare professional or personal doctor about your physical or mental health ailments. The statement focuses on how your health affects your working ability and ability to complete work-related activities.
The pain questionnaire is asking how pain limits the individual and how often they are experiencing the pain. This form will also ask about any medications they are taking and any side effects the medication is causing. Side effects from medications can also help you show how else your client is limited.
What Is a Medical Source Statement? A medical source statement is a form completed by your doctor summarizing how limited you are physically and mentally as a result of your conditions. This document will help the SSA determine whether you are disabled.
If you have a chronic pain condition that renders you incapable of working, you may qualify for Social Security disability (SSD) benefits. However, qualifying can be a challenge because the Social Security Administration has a strict definition of what it means to be disabled.
How to Answer Disability Questionnaires Write clearly and legibly. Avoid erasures as much as possible. Do not leave any section of the form blank (unless otherwise specified). Give consistent answers. Answer the questions truthfully. Follow the instructions on the form.
What Should Your Doctor Disability Letter Include? A detailed explanation of your condition and limitations. Medical evidence of your condition and limitations. Details on how your condition limits daily activities and ability to maintain gainful employment.

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A medical source statement is a document provided by a medical professional that outlines a patient's medical condition, functional limitations, and how these impact their daily life. It often includes specific information about diagnoses, treatment plans, and recommendations for care.
Typically, medical source statements are filed by healthcare providers such as doctors, psychologists, or other licensed medical professionals who have treated the patient and can provide detailed information about their medical condition.
To fill out a medical source statement, the provider should clearly describe the patient's medical history, current symptoms, limitations in daily activities, and any treatments administered. It is important to use clear language and be as specific as possible about the patient's abilities and limitations.
The purpose of a medical source statement is to provide evidence of a patient's medical conditions and limitations, which can be used to support applications for disability benefits, accommodations, or other support services.
The information that must be reported on a medical source statement typically includes the patient's diagnosis, treatment received, functional limitations, prognosis, and any recommendations for accommodations or further care.
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