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Medical Source Statement Concerning the Nature and Severity of an Individuals Physical Impairment NAME OF PATIENT:___ SSN: ___ DATE OF BIRTH: ___ PHYSICIAN: ___ Based on the following factors:(1)
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How to fill out medical source statement concerning

01
Obtain the medical source statement form from the appropriate healthcare provider.
02
Fill out the patient's personal information, including name, date of birth, and contact information.
03
Provide detailed information about the patient's medical condition, including diagnosis, symptoms, and treatment plan.
04
Clearly state how the medical condition affects the patient's ability to work or perform daily activities.
05
Include any supporting medical documentation, such as test results or treatment history.
06
Review the completed form for accuracy and completeness before submitting it to the relevant party.

Who needs medical source statement concerning?

01
Individuals applying for disability benefits
02
Employees requesting accommodations in the workplace
03
Insurance companies evaluating claims
04
Legal professionals representing clients in disability cases
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Medical source statement is a document completed by a medical professional that provides information about a patient's medical conditions, limitations, and ability to perform tasks.
Medical professionals such as doctors, nurses, or therapists may be required to fill out a medical source statement concerning a patient.
Medical professionals should carefully assess and document the patient's medical history, current conditions, and limitations in the medical source statement form.
The purpose of a medical source statement is to provide a detailed and accurate assessment of a patient's medical conditions and abilities for use in disability claims or legal proceedings.
Medical source statement concerning must report the patient's medical history, current conditions, treatment plan, functional limitations, and prognosis.
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