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SOCIAL SECURITY ADMINISTRATION Office of Disability Adjudication and Reviewer Approved OMB No.09600662MEDICAL SOURCE STATEMENT OF ABILITY TO DO CORRELATED ACTIVITIES (PHYSICAL)NAME OF INDIVIDUALSOCIAL

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How to fill out medical source statement of

01

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

02

Start by identifying the patient and providing their personal information, including name, date of birth, and contact details.

03

Specify the purpose of the medical source statement, whether it is for a disability claim, insurance coverage, or other purposes.

04

Begin the body of the statement by documenting the patient's medical history, including any diagnosed conditions, treatments received, and medications currently being taken.

05

Include relevant details about the patient's physical and mental health limitations, such as mobility restrictions, chronic pain levels, cognitive impairments, or emotional disturbances.

06

Provide a detailed assessment of the patient's functional limitations and abilities, considering their ability to perform tasks related to self-care, mobility, communication, and work-related activities.

07

Include any objective medical evidence, test results, or imaging studies that support the stated limitations and impairments.

08

Summarize the prognosis for the patient's condition, including the expected duration of limitations and the potential for improvement or worsening over time.

09

Conclude the statement with your professional opinion on the patient's functional capacities and any recommendations for accommodations or treatments that could help improve their condition.

10

Sign and date the medical source statement, providing your name, contact information, and professional credentials.

Who needs medical source statement of?

01

Medical source statements are typically needed by individuals who require documentation of their medical conditions and functional limitations. This may include individuals applying for disability benefits, seeking insurance coverage, pursuing a legal claim, or undergoing a vocational rehabilitation process. Healthcare providers, physicians, psychologists, and other medical professionals may also need medical source statements to support their treatment plans and communicate the impact of a patient's condition on their daily lives.

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What is medical source statement of?

Medical source statement is a document completed by a medical professional that provides information about a patient's medical condition, functional limitations, and ability to work.

Who is required to file medical source statement of?

Medical professionals including doctors, nurses, and therapists are required to file medical source statements.

How to fill out medical source statement of?

Medical professionals must accurately report the patient's medical history, current symptoms, and functional limitations 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 an objective assessment of the patient's medical condition and ability to work.

What information must be reported on medical source statement of?

Information such as the patient's diagnosis, prognosis, treatment plan, and functional limitations must be reported on the medical source statement.

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