Get the free FIBROMYALGIA MEDICAL SOURCE STATEMENT

FIBROMYALGIA MEDICAL SOURCE STATEMENT From: Re:(Name of Patient) (Social Security No.) Please answer the following questions concerning your patients impairments. Attach all relevant treatment notes,

How to fill out fibromyalgia medical source statement

How to fill out fibromyalgia medical source statement

1. To fill out a fibromyalgia medical source statement, follow these steps:
2. Start by collecting all relevant medical records, including diagnostic tests, treatment plans, and any previous medical opinions related to fibromyalgia.
3. Review the Social Security Administration's criteria for evaluating fibromyalgia disability claims to understand the specific information they require.
4. Begin the statement by providing a brief introduction, including the patient's name, date of birth, and a statement that you have treated or evaluated the patient for fibromyalgia.
5. Describe the patient's medical history, including how long they have experienced symptoms, any previous treatments or surgeries related to fibromyalgia, and any co-existing conditions that may have an impact on their symptoms.
6. Provide a detailed description of the patient's symptoms, including the frequency, duration, and intensity of pain, fatigue, cognitive difficulties, and other common fibromyalgia symptoms. Use specific examples or observations to support your statements.
7. Discuss the impact of these symptoms on the patient's ability to function in daily activities, such as work, household chores, personal care, and social interactions. Include any limitations or restrictions the patient experiences due to their fibromyalgia symptoms.
8. If applicable, mention any objective medical findings or test results that support the diagnosis of fibromyalgia and the severity of the patient's symptoms. This may include tender points examinations, imaging studies, or laboratory test results.
9. Consider addressing the patient's response to various treatments, including the effectiveness of medications, physical therapy, lifestyle modifications, or alternative therapies in managing their symptoms.
10. Conclude the statement with a summary of your professional opinion regarding the patient's functional abilities and limitations due to fibromyalgia. If you believe the patient meets the criteria for disability according to the Social Security Administration's guidelines, include a statement supporting this opinion.
11. Review and proofread the completed statement for accuracy and completeness before submitting it to the appropriate authorities or parties involved in the patient's disability claim.

Who needs fibromyalgia medical source statement?

1. A fibromyalgia medical source statement may be needed for individuals who are seeking disability benefits or accommodations based on their fibromyalgia condition.
2. This statement is typically requested by insurance companies, government agencies like the Social Security Administration, or employers when evaluating and determining the eligibility of an individual for disability benefits or workplace accommodations.
3. People with fibromyalgia who require support in terms of financial assistance or workplace modifications may benefit from obtaining a medical source statement to provide objective information about their condition and its impact on their functional abilities.

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What is fibromyalgia medical source statement?

A fibromyalgia medical source statement is a document completed by a healthcare provider that outlines the patient's symptoms, limitations, and medical history related to fibromyalgia.

Who is required to file fibromyalgia medical source statement?

Fibromyalgia patients who are seeking disability benefits or accommodations may be required to have their healthcare provider fill out a fibromyalgia medical source statement.

How to fill out fibromyalgia medical source statement?

To fill out a fibromyalgia medical source statement, the healthcare provider must provide detailed information about the patient's diagnosis, symptoms, functional limitations, and treatment plan.

What is the purpose of fibromyalgia medical source statement?

The purpose of a fibromyalgia medical source statement is to provide an accurate and detailed assessment of the patient's condition to support their disability claim or request for accommodations.

What information must be reported on fibromyalgia medical source statement?

Information that should be reported on a fibromyalgia medical source statement includes the patient's medical history, diagnosis, symptoms, functional limitations, treatment plan, and prognosis.