Residual Functional Capacity Form | RFC | Medical Source Statement | MSS

Your impairments, and any related symptoms, such as pain, may cause physical and mental limitations that affect what you can do in a work setting. Your “residual functional capacity” is the most you can still do despite your limitations. Social Security will assess your residual functional capacity based on all the relevant evidence in your case record.

The Residual Functional Capacity Form

When you apply for SSDI and/or SSI, your claim is assigned to a Disability Determination Services (DDS) claims examiner. If you are not engaging in substantial gainful activity and a determination or decision cannot be made on the basis of medical factors alone (for example, when the impairment is “severe” because it has more than a minimal effect on the ability to do basic work activities yet does not meet or equal in severity the requirements of any impairment in the Listing of Impairments), the sequential evaluation process generally must continue with an identification of the your functional limitations and restrictions and an assessment of your RFC.

DDS’s Residual Functional Capacity Form

During the processing of the claim, the DDS examiner will have a DDS physician and/or psychological consultant review the evidence in the claimant’s medical file and give an assessment as to the claimant’s residual functional capacity, taking into account the claimant’s medical conditions and how such conditions affect the claimant’s ability to work.  The DDS Physician will then complete an RFC form, typically a Mental Residual Functional Capacity Assessment (Form SSA-4734-F4-SUP) or a Physical Residual Functional Capacity Assessment (SSA-4734-BK).  The physical RFC form will give opinions as to the claimant’s physical limitations, such as how long the claimant may be expected to sit, stand, walk, etc. In a mental health claim, the mental RFC form will give opinions as to how the claimant’s mental impairments would limit the claimant’s ability to perform the mental demands of a job, such as how the person would handle a work environment if they have poor memory, rational thinking problems, difficultly responding to the stress of a route work setting, difficulty getting along with co-workers and the general public, etc.

When issuing a decision on a claimant’s case, the DDS examiner will explain the reasoning behind his or her decision to approve or deny the claim. One of the key pieces of evidence in this evaluation is will be the Residual Functional Capacity Form(s).

The Physical RFC Form

The DDS physician will read the claimant’s medical file to form his or her medical opinions.

In case you haven’t realized it by this point, many RFC forms are filled out based only on the medical records in the claim file. These doctors have never met the claimant or performed an examination of the claimant in person. Their opinions are only based upon the paperwork in the file.

After reviewing the file, the DDS physician will fill out an RFC form to rate the claimant’s residual functional capacity.  The assessment will give opinions as to the claimant’s ability to engage in normal daily activities taking into account the individual’s conditions. For instance, the physical RFC form give the DDS physician’s opinions as to how long a claimant can sit, stand, walk, crouch, stoop, balance, and kneel. The RFC form will also provide opinions as to how much weight the claimant can lift and carry. Whether there are any restrictions in pushing, pulling, reaching, grasping/handling larger objects, fingering smaller objects, and feeling with the skin.

Mental RFC Form

In a mental health case, the DDS psychologist or psychiatrist will review the claimant’s medical file.  The DDS psychological consultant will then fill out a mental RFC form.  This mental Residual Functional Capacity form will evaluate and rate the claimant’s mental impairments.  The doctor will first evaluate the claimant’s mental symptoms (such as poor memory and/or concentration, low energy, impaired or illogical thinking, and so on). The mental RFC form may further evaluate the claimant’s ability to maintain concentration and attention, and evaluate the claimant’s ability to interact socially in work settings, ability to understand and remember instructions, ability to respond appropriately to changes in the work setting, and ability to successfully engage in SRRTs (simple, routine, repetitive tasks) and ADLs (activities of daily living).

Us you can imagine, RFC forms completed by DDS doctors are rarely helpful to any claimant’s disability claim. The unfortunate reality is that DDS RFC forms are used to deny claims far more often than they are used to approve claims.  This is why you should try and have your own treating doctor fill out an RFC form to assist you in your claim for benefits.

RFC Forms Completed by Your Own Treating Doctor

RFC forms completed by your own treating doctor can be extremely helpful to you in your hearing before an Administrative Law Judge (ALJ). Your medical records state your diagnoses, or impairments.  However, medical records do not often identify your level of impairment due to your medical conditions.  An RFC form by your treating physician will “bridge the gap” between diagnosis and impairment.  The opinions in an RFC form can be of great benefit at the hearing when questioning the vocational expert.  You are far more likely to get a vocational expert at a hearing testify that there are “no jobs” taking into account the limitations identified in an RFC form filled out by one of your doctors, as opposed to the VE’s testimony in response to the limitations identified in the DDS RFC form (where the VE will likely identify hundreds of thousands of jobs available with such limitations).
 

The “Treating Physician” Rule

Social Security gives substantial weight to the opinions of a disability claimant’s personal physician, or treating physician. This makes sense.  The treating physician has a history of treating your condition.  The treating physician likely provided hands-on medical care in person and has first-hand knowledge of a your medical condition and prognosis.  As such, your treating doctor is in a better and more informed position to give an opinion as to your medical impairments. For these reasons, administrative law judges are to give “substantial weight” to the opinions of treating physicians, especially when those opinions are backed up by the medical records and when those opinions are properly documented in detailed RFC forms.

Why A Treating Doctor’s RFC Forms Are Even Better Than Medical Records

Many claimants may be thinking: “If there is so much medical evidence in my claim and the evidence is strong, why do I need an RFC form from my doctor, psychologist or psychiatrist?” As stated above, medical records very rarely translate the patient’s diagnoses into level of impairment.  They even more rarely draw conclusions as to the patient’s ability to work or not. Because judges are not doctors who can translate the symptoms and test results contained in medical records into level of impairment, it will be of great benefit to have your doctor fill out a Residual Functional Capacity Form for the judge.

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