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Applying for Social Security Disability Insurance (SSDI) can be challenging, especially when you’re dealing with a serious medical condition. You know your health limits your ability to work, but now you have to prove it to the Social Security Administration (SSA). That’s where medical records come in.
The SSA doesn’t make decisions based on what’s in your file. That’s why having the proper medical documentation can make or break your SSDI claim. This blog explains what kinds of medical records you need and why they matter.
Why Medical Records Are So Important
Medical records are the foundation of every SSDI claim. The SSA uses these documents to determine whether your physical or mental condition meets its definition of disability.
A successful claim shows that your condition:
- Is medically documented by a licensed professional,
- Prevents you from performing “substantial gainful activity” (SGA), and
- Has lasted (or is expected to last) at least 12 months or result in death.
If your records are missing, vague, or inconsistent, your claim is more likely to be denied—even if your condition is severe. That’s why it’s essential to gather comprehensive, clear, and up-to-date medical evidence before filing.
The Key Medical Records You’ll Need
Your SSDI application should paint a complete picture of your health. This includes not only your diagnosis but also how your condition affects your ability to work and perform daily activities. Here are the types of records that matter most:
1. Diagnosis and Treatment Records
The SSA needs to see that your condition has been officially diagnosed and treated. These records often include:
- Office notes from primary care doctors and specialists
- Hospital discharge summaries
- Imaging reports (MRIs, X-rays, CT scans)
- Lab results and pathology reports
If your diagnosis is unclear or inconsistent across different providers, it could raise red flags. That’s why we often recommend getting a full copy of your treatment history before submitting your application.
2. Ongoing Treatment and Medication History
A one-time doctor’s visit isn’t enough. The SSA wants to see that you’ve been actively treated for your condition over time. This might include:
- Records of surgeries, therapy sessions, or rehabilitation
- A list of prescribed medications (and any side effects)
- Details on emergency room visits or hospitalizations
Consistency and frequency of care help demonstrate that your condition is severe and persistent.
3. Functional Limitations
It’s not enough to show that you have a medical condition—you must also show how it limits your ability to work. Look for:
- Notes explaining how your condition impacts walking, lifting, standing, concentrating, or interacting with others
- Descriptions of “good” days and “bad” days
- Any accommodations needed in daily life (e.g., assistive devices or support from others)
These records are often the clearest window into how your condition affects your life—and your ability to earn an income.
4. Mental Health Documentation
If you’re applying based on depression, PTSD, anxiety, or another mental health condition, documentation is just as critical. You’ll want to include:
- Progress notes from therapists or counselors
- Psychiatric evaluations
- Any cognitive or psychological testing
Mental health conditions are just as valid as physical ones—but proving them often requires more detailed records.
Doctor’s Statements Can Strengthen Your Claim
In addition to standard records, a Medical Source Statement or Residual Functional Capacity (RFC) form can be a powerful addition to your application.
These are letters or forms your doctor completes that explain—in plain terms—what you can and can’t do. For example, a physician might note that you’re unable to sit for more than 30 minutes at a time, or that you miss multiple days of work per month due to flare-ups.
SSA gives the most weight to doctors who have treated you consistently over time—especially specialists. A detailed letter from a long-term provider can be one of the strongest pieces of evidence in your case.
How to Stay Organized
Getting all this information together can feel like a second job. Here are a few tips:
- Keep a list of every doctor or clinic you’ve visited
- Request your records early (they can take weeks to arrive)
- Make sure you include both physical and mental health providers
- Store everything in one place so you’re ready if the SSA asks for more
Better yet, work with a Michigan disability attorney who can help you avoid common mistakes and keep your claim on track.
Let Grech Law Firm Help You Build a Strong SSDI Claim
At Grech Law Firm, we’ve helped individuals across Michigan secure the disability benefits they deserve. We understand how challenging it can be to manage your health while navigating the complexities of the healthcare system.
Let us step in and take some of that weight off your shoulders. We’ll work with your doctors, gather your medical records, and make sure nothing gets overlooked. Contact us to consult with an experienced disability lawyer.