Why Medical Documentation Matters

The SSA does not approve SSDI claims based on your word alone. Instead, decisions are made using objective medical evidence from acceptable sources. The stronger and more complete your medical documentation, the higher your chances of approval.

Types of Medical Documentation Needed in Kentucky

Here’s what you’ll need to include with your SSDI application:

1. Medical Records from Healthcare Providers

• Hospital records, clinic notes, and physician reports.
• Dates of visits, treatments, and outcomes.
• Records from specialists (neurologists, orthopedists, psychiatrists, etc.) relevant to your condition.

2. Test Results and Imaging

• X-rays, MRIs, CT scans, and lab tests.
• Diagnostic tests that confirm the severity of your condition.

3. Treatment History

• Records of surgeries, medications, and therapies you’ve undergone.
• Evidence of whether treatments have improved or failed to improve your condition.

4. Physician Statements

• A detailed letter or report from your treating doctor.
• Opinions on how your condition limits your ability to work.
• Prognosis for your recovery or long-term limitations.

5. Mental Health Records (if applicable)

• Psychiatric evaluations, therapy notes, and counseling records.
• Documentation of mental health conditions like depression, PTSD, or anxiety.

Additional Requirements in Kentucky

The SSA may request a Consultative Examination (CE) if your medical records are incomplete. This exam is performed by an SSA-approved doctor to provide additional medical evidence.

Tips for Stronger Documentation

• Make sure your records are current and updated.
• Ask your doctor to include specific limitations (e.g., inability to lift, stand for long periods, or concentrate).
• Keep copies of everything you submit.