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What should an SSDI medical report contain in New Jersey?

Previous posts here have covered many aspects of the Social Security Disability Insurance process, including applications, reconsiderations, federal regulations, hearings in front of an Administrative Law Judge and appeals. We have also discussed the specific evidentiary requirements the Social Security Administration adheres to for specific types of injuries or ailments. As we have seen, the SSA requires that any injury used as a basis for an application for SSDI benefits result in a "medically determinable" disability. To meet this standard, the state agency responsible for processing SSDI claims will usually use medical reports from the injured person's doctor. So, what information should be in this type of report?

The New Jersey Division of Disability Determination Services website has a brief discussion of what these reports should contain. Generally, these reports will be from the treating physician who has an ongoing medical relationship with the applicant. The state requires that the medical report contain a history of the patient and the injury, a diagnosis backed up by clinical and laboratory findings and there should be a description of the any response to treatment of the injury.

Further, any other objective information that can be gleaned from a patient's medical chart should be included in the report. Lastly, it is very important that the physician include some statement as to that doctor's opinion with regard to work activities the patient can perform despite the injury. The agency makes clear that simply forwarding diagnosis information will not be sufficient to back a claim for SSDI.

While the agency adjudicating the disability application may reach out to your doctor for these medical reports, it may be in your best interest to be proactive and get one from the physician to include in the initial application. Not only may this make the adjudication process quicker, it may allow you to review the report to ensure that the required information is present.

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