Sample Doctor Letter
DATE OF REQUEST
Dr. XXXX Fax # or address Dr. ZZZZ Fax # or address
Dear Dr. ZZZZ and Dr. XXXX:
I am in the process of working with the Social Security Administration (SSA) to obtain my Disability Insurance. (OR, I AM IN THE PROCESS OF WORKING WITH MY LONG TERM DISABILITY (LTD) CCOMPANY TO OBTAIN MY LTD INSURANCE.) My appointment is scheduled for YOUR DATE. I am taking the liberty of faxing this information to you, and request that you fax back to me (111-111-1111) the requested information no later than [Deadline Date].
Your assistance is needed in this process as follows:
1. Attached is a document that explains what I need from you; why I need the information; and how to make the direct links between my illness symptoms and their impact on my life.
2. Attached is a copy of a Residual Functional Capacity Questionnaire for you to complete on me, based on your findings. I have also included a completed RFC describing how I’ve experience the impact.
3. A letter to the SSA, (or, to the LTD Insurance Company) on your letterhead, stating that you have been treating me since (appropriate date for Dr. XXXX; appropriate date for Dr. ZZZZ).
· Your prognosis about my condition. (Dr. ZZZZ is calling it chronic progressive. If you two could be consistent, it would help the decision makers.)
· Your prognosis about my ability to return to any type of work (never).
· A statement about my overall physical condition. For example: I also am providing you by fax, a copy of how I believe that each bodily system is impacted by YOUR ILLNESS that I am providing to SSA/LTD. A statement could look like this:
“[Your Name]YOUR ILLNESS symptoms have been steadily increasing in magnitude since conclusive diagnosis through MRI and spinal tap in (appropriate date). The impact of these symptoms on the patient’s daily activities is adequately described in my chart notes, and in the patient’s diary notes.
Due to the magnitude, scope, and complexity of this patient’s condition, it is unreasonable at this time to expect that she will be able to work at any time in the near or distant future. At best, medication can only decrease the rate of increase of this chronic disease. In my opinion, this patient would be a liability to any employer, and would be unable to sustain gainful employment of any sort, due to her physical, mental, emotional, and psychological limitations.”
Either of you may add, if you so wish, that you had to cut me back in work hours from a full time+ of 65-70 hours per week to a part time of 40 hours in July or August of 1999, and to no more than 32 hours since 4-1-00. I have been on full Long Term Disability with no work since 4-1-01.
The following SSA criteria for your information comes from their Blue Book used to evaluate candidates for SSDI:
Disability Evaluation under Social Security (The Blue Book) Medical criteria for evaluating Social Security disability claims
Medical Evidence from Treating Sources
Currently, many disability claims are decided on the basis of medical evidence from treating sources. SSA regulations place special emphasis on evidence from treating sources because they are likely to be the medical professionals most able to provide a detailed longitudinal picture of the claimant's impairments and may bring a unique perspective to the medical evidence that cannot be obtained from the medical findings alone or from reports of individual examinations or brief hospitalizations. Therefore, timely, accurate, and adequate medical reports from treating sources accelerate the processing of the claim because they can greatly reduce or eliminate the need for additional medical evidence to complete the claim.
Finally, Dr. ZZZZ, as my Primary Doctor, could you please have a copy of all information in my medical file pertaining to the diagnosis of YOUR ILLNESS. The information should include, but not be limited to: Doctor notes, chart notes, lab results, x-ray results, MRI results, Spinal Tap results, the chart notes from the Physical and Occupational therapists that I saw through Dr. PPPPP.
(Note: I have Dr. PPPPP’s first write-up on me.)
I do not need this info by my SSA appointment date. However, as soon as possible would be nice. If someone could call me at [YOUR PHONE #] I’ll come by in person and pick up the information.
THANK YOU FOR YOUR CONTINUED SUPPORT AND HELP!
Dr. XXXX Fax # or address Dr. ZZZZ Fax # or address
Dear Dr. ZZZZ and Dr. XXXX:
I am in the process of working with the Social Security Administration (SSA) to obtain my Disability Insurance. (OR, I AM IN THE PROCESS OF WORKING WITH MY LONG TERM DISABILITY (LTD) CCOMPANY TO OBTAIN MY LTD INSURANCE.) My appointment is scheduled for YOUR DATE. I am taking the liberty of faxing this information to you, and request that you fax back to me (111-111-1111) the requested information no later than [Deadline Date].
Your assistance is needed in this process as follows:
1. Attached is a document that explains what I need from you; why I need the information; and how to make the direct links between my illness symptoms and their impact on my life.
2. Attached is a copy of a Residual Functional Capacity Questionnaire for you to complete on me, based on your findings. I have also included a completed RFC describing how I’ve experience the impact.
3. A letter to the SSA, (or, to the LTD Insurance Company) on your letterhead, stating that you have been treating me since (appropriate date for Dr. XXXX; appropriate date for Dr. ZZZZ).
· Your prognosis about my condition. (Dr. ZZZZ is calling it chronic progressive. If you two could be consistent, it would help the decision makers.)
· Your prognosis about my ability to return to any type of work (never).
· A statement about my overall physical condition. For example: I also am providing you by fax, a copy of how I believe that each bodily system is impacted by YOUR ILLNESS that I am providing to SSA/LTD. A statement could look like this:
“[Your Name]YOUR ILLNESS symptoms have been steadily increasing in magnitude since conclusive diagnosis through MRI and spinal tap in (appropriate date). The impact of these symptoms on the patient’s daily activities is adequately described in my chart notes, and in the patient’s diary notes.
Due to the magnitude, scope, and complexity of this patient’s condition, it is unreasonable at this time to expect that she will be able to work at any time in the near or distant future. At best, medication can only decrease the rate of increase of this chronic disease. In my opinion, this patient would be a liability to any employer, and would be unable to sustain gainful employment of any sort, due to her physical, mental, emotional, and psychological limitations.”
Either of you may add, if you so wish, that you had to cut me back in work hours from a full time+ of 65-70 hours per week to a part time of 40 hours in July or August of 1999, and to no more than 32 hours since 4-1-00. I have been on full Long Term Disability with no work since 4-1-01.
The following SSA criteria for your information comes from their Blue Book used to evaluate candidates for SSDI:
Disability Evaluation under Social Security (The Blue Book) Medical criteria for evaluating Social Security disability claims
Medical Evidence from Treating Sources
Currently, many disability claims are decided on the basis of medical evidence from treating sources. SSA regulations place special emphasis on evidence from treating sources because they are likely to be the medical professionals most able to provide a detailed longitudinal picture of the claimant's impairments and may bring a unique perspective to the medical evidence that cannot be obtained from the medical findings alone or from reports of individual examinations or brief hospitalizations. Therefore, timely, accurate, and adequate medical reports from treating sources accelerate the processing of the claim because they can greatly reduce or eliminate the need for additional medical evidence to complete the claim.
Finally, Dr. ZZZZ, as my Primary Doctor, could you please have a copy of all information in my medical file pertaining to the diagnosis of YOUR ILLNESS. The information should include, but not be limited to: Doctor notes, chart notes, lab results, x-ray results, MRI results, Spinal Tap results, the chart notes from the Physical and Occupational therapists that I saw through Dr. PPPPP.
(Note: I have Dr. PPPPP’s first write-up on me.)
I do not need this info by my SSA appointment date. However, as soon as possible would be nice. If someone could call me at [YOUR PHONE #] I’ll come by in person and pick up the information.
THANK YOU FOR YOUR CONTINUED SUPPORT AND HELP!
