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SOCIAL SECURITY ADMINISTRATION OFFICE OF DISABILITY ADJUDICATION AND REVIEW Form Approved OMS No. 09600662 MEDICAL SOURCE STATEMENT OF ABILITY TO DO CORRELATED ACTIVITIES (MENTAL) NAME OF INDIVIDUAL

How to fill out medical source statement of

How to fill out a medical source statement of:

1. Gather all relevant medical records and reports: Start by collecting all medical records pertaining to the patient's condition. This may include doctor's notes, test results, imaging reports, and any other relevant documentation.
2. Review the form: Carefully read through the medical source statement of form to familiarize yourself with its structure and requirements. Take note of any specific information or details that need to be provided.
3. Identify the patient's medical condition: Clearly identify and understand the patient's medical condition. This is crucial as it will help in accurately completing the form. Review the patient's diagnosis and any related information from the medical records.
4. Provide detailed medical history: Fill out the necessary sections on the form that require the patient's medical history. This may include information about past treatments, surgeries, medications, and their effects on the patient's condition.
5. Describe current symptoms and limitations: In this section, clearly describe the patient's current symptoms and limitations resulting from their medical condition. Include specific details such as pain intensity, frequency, and any impact on daily activities or work capacity.
6. Assess functional limitations: Determine any functional limitations the patient experiences due to their medical condition. This may involve physical, cognitive, or psychological impairments that affect their ability to perform certain tasks or maintain employment.
7. Provide objective medical evidence: Support the claims made on the medical source statement of form with objective medical evidence. This can include test results, imaging reports, clinical observations, or other supporting documentation that validate the patient's condition and limitations.
8. Include professional opinion: Use the space provided on the form to provide your professional opinion regarding the patient's medical condition and its impact on their ability to work or perform certain activities. Clearly explain your reasoning and provide any additional recommendations for treatment or accommodation if applicable.

Who needs a medical source statement of:

1. Individuals seeking disability benefits: Individuals who are applying for disability benefits, such as Social Security Disability Insurance (SSDI) or Long-Term Disability (LTD) insurance, often require a medical source statement. This statement helps establish their medical condition as well as the functional limitations and impairments that prevent them from performing substantial gainful activity.
2. Employees requesting workplace accommodations: In some cases, employees may require a medical source statement to request workplace accommodations due to a medical condition. This statement helps their employer understand the specific limitations and adjustments needed to ensure a safe and suitable working environment.
3. Individuals involved in legal proceedings: In legal proceedings, such as personal injury cases or workers' compensation claims, a medical source statement can provide crucial evidence regarding the extent of injuries or medical conditions. This statement helps support the individual's claim and may influence the compensation or benefits they receive.

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What is medical source statement of?

Medical source statement is a medical document completed by a healthcare provider that outlines a patient's medical conditions, limitations, and ability to work.

Who is required to file medical source statement of?

Healthcare providers, such as doctors, nurse practitioners, and therapists, are required to file medical source statements for their patients.

How to fill out medical source statement of?

Healthcare providers must carefully assess their patient's medical history, perform any necessary medical examinations, and accurately document their findings on the medical source statement form.

What is the purpose of medical source statement of?

The purpose of the medical source statement is to provide detailed information about a patient's medical condition and functional limitations, which can be used in determining eligibility for disability benefits, treatment plans, or accommodations in the workplace.

What information must be reported on medical source statement of?

The medical source statement should include the patient's diagnosis, treatment plan, functional limitations, prognosis, and any restrictions on work-related activities.