Medical Records

Revised on: September 7, 2024

  1. The diagnosis of a disabling impairment must be made by an acceptable medical source within 5 years of the SSI application. Once the impairment has been established, SSA considers evidence from other treating providers. Acceptable sources of medical evidence include:
    1. Licensed physicians (medical or osteopathic doctors);
    2. Licensed psychiatrists or psychologists;
    3. Optometrists (for purposes of establishing visual disorders only);
    4. Licensed podiatrists (for purposes of establishing impairments of the foot, or foot and ankle only); and
    5. Qualified speech-language pathologists (for purposes of establishing speech or language impairments only).
  2. DDDS uses the Medical Evidence of Record (MER) as the primary source of medical evidence to determine disability. This includes:
    1. Hospital and clinic records;
    2. Records from the treating physician;
    3. Evaluations by specialists; and
    4. Clinical and laboratory findings (such as: x-rays, lab tests, and psychological testing).
  3. DDDS arranges consultative examinations with contracted physicians and psychologists (including transportation when requested) when medical evidence does not contain sufficient information to make a disability decision.
  4. When completing the Internet Adult Disability Report i3368 for initial applications and the iAppeal for appeals, list the CSO as a source of medical records. All DDDS offices have access to the client's CSD Electronic Case Record.
  5. For TANF clients, use Support Services (see WorkFirst Handbook: Support Services Directory) to obtain additional objective medical evidence when the available evidence does not provide enough information to determine if the client appears to meet SSA disability criteria.

Attorney Requests for Records

When an attorney representing a client receiving SSI Facilitation services makes a request for additional medical records to assist with the SSI appeal process, SSI Facilitators will follow CSD Procedure: Attorney Requests for Records.

EXAMPLE: The SSIF receives a phone call from an attorney asking DSHS to pay for copies of medical records from the local community hospital. The attorney asks for the complete medical records (e.g. "all records" or "all history") and says that they are being used to "prepare the case for hearing." The SSIF asks what specific records are needed, why those specific records are needed, and if all or part of them are included in the DDDS or CSO records already provided to the attorney. The attorney responds by saying they just want to make sure they have everything. The SSIF denies the request because the need for the records has not been clearly demonstrated.