Acceptable Medical Sources or Doctors to Establish a Medically Determinable Impairment

I was recently asked whether a Residual Functional Capacity evaluation by a psychologist carries any weight in a Social Security disability determination. In other words, can it be discounted because a psychologist is not a psychiatrist or medical doctor?

Let’s go right to the Code of Federal Regulations to answer this question.

Acceptable Medical Sources

CFR § 404.1513, subsection (a), defines who is (and therefore who is not) an “acceptable medical source” who can provide medical and other evidence of your impairment(s):

(a) Sources who can provide evidence to establish an impairment. We need evidence from acceptable medical sources to establish whether you have a medically determinable impairment(s). See § 404.1508. Acceptable medical sources are—

(1) Licensed physicians (medical or osteopathic doctors);

(2) Licensed or certified psychologists. Included are school psychologists, or other licensed or certified individuals with other titles who perform the same function as a school psychologist in a school setting, for purposes of establishing mental retardation, learning disabilities, and borderline intellectual functioning only;

(3) Licensed optometrists, for purposes of establishing visual disorders only (except, in the U.S. Virgin Islands, licensed optometrists, for the measurement of visual acuity and visual fields only);

(4) Licensed podiatrists, for purposes of establishing impairments of the foot, or foot and ankle only, depending on whether the State in which the podiatrist practices permits the practice of podiatry on the foot only, or the foot and ankle; and

(5) Qualified speech-language pathologists, for purposes of establishing speech or language impairments only. For this source, “qualified” means that the speech-language pathologist must be licensed by the State professional licensing agency, or be fully certified by the State education agency in the State in which he or she practices, or hold a Certificate of Clinical Competence from the American Speech-Language-Hearing Association.

(emphasis added).

So we see that a psychologist is an acceptable medical source. See the section below titled, “Residual Functional Capacity Forms and Statements About What You Can Still Do” for more information about how a psychologist’s opinions in an RFC are treated.

Medical Reports and What They Should Include

CFR § 404.1513, subsection (b), goes on to define what medical evidence and reports in support of a disability claim should include:

(b) Medical reports. Medical reports should include—

(1) Medical history;

(2) Clinical findings (such as the results of physical or mental status examinations);

(3) Laboratory findings (such as blood pressure, x-rays);

(4) Diagnosis (statement of disease or injury based on its signs and symptoms);

(5) Treatment prescribed with response, and prognosis; and

(6) A statement about what you can still do despite your impairment(s) based on the acceptable medical source’s findings on the factors under paragraphs (b)(1) through (b)(5) of this section (except in statutory blindness claims). Although we will request a medical source statement about what you can still do despite your impairment(s), the lack of the medical source statement will not make the report incomplete. See § 404.1527.

(emphasis added).

Residual Functional Capacity Forms and Statements About What You Can Still Do

CFR § 404.1513, subsection (c), then continues to define what medical evidence and reports in support of a disability claim should include, including Residual Functional Capacity assessments and Physical Capacity Evaluation forms:

(c) Statements about what you can still do. At the administrative law judge and Appeals Council levels, we will consider residual functional capacity assessments made by State agency medical and psychological consultants, and other program physicians and psychologists to be “statements about what you can still do” made by nonexamining physicians and psychologists based on their review of the evidence in the case record. Statements about what you can still do (based on the acceptable medical source’s findings on the factors under paragraphs (b)(1) through (b)(5) of this section) should describe, but are not limited to, the kinds of physical and mental capabilities listed as follows (See §§ 404.1527 and 404.1545(c)):

(1) The acceptable medical source’s opinion about your ability, despite your impairment(s), to do work-related activities such as sitting, standing, walking, lifting, carrying, handling objects, hearing, speaking, and traveling; and

(2) In cases of mental impairment(s), the acceptable medical source’s opinion about your ability to understand, to carry out and remember instructions, and to respond appropriately to supervision, coworkers, and work pressures in a work setting.

(emphasis added).

Evidence From Other Sources, Including Chiropractors, Nurse-Practitioners and Physicians’ Assistants

CFR § 404.1513, subsection (d), describes how the Social Security Administration will in fact consider medical evidence and reports from medical providers other than medical doctors, physicians and psychologists:

(d) Other sources. In addition to evidence from the acceptable medical sources listed in paragraph (a) of this section, we may also use evidence from other sources to show the severity of your impairment(s) and how it affects your ability to work. Other sources include, but are not limited to—

(1) Medical sources not listed in paragraph (a) of this section (for example, nurse-practitioners, physicians’ assistants, naturopaths, chiropractors, audiologists, and therapists);

(2) Educational personnel (for example, school teachers, counselors, early intervention team members, developmental center workers, and daycare center workers);

(3) Public and private social welfare agency personnel; and

(4) Other non-medical sources (for example, spouses, parents and other caregivers, siblings, other relatives, friends, neighbors, and clergy).

(emphasis added).

The Evidence Must be Complete and Detailed Enough to Allow SSA To Make a Disability Decision

CFR § 404.1513, subsection (e), requests that the evidence in the record be complete and detailed enough to allow Social Security to make a disability determination:

(e) Completeness. The evidence in your case record, including the medical evidence from acceptable medical sources (containing the clinical and laboratory findings) and other medical sources not listed in paragraph (a) of this section, information you give us about your medical condition(s) and how it affects you, and other evidence from other sources, must be complete and detailed enough to allow us to make a determination or decision about whether you are disabled or blind. It must allow us to determine—

(1) The nature and severity of your impairment(s) for any period in question;

(2) Whether the duration requirement described in § 404.1509 is met; and

(3) Your residual functional capacity to do work-related physical and mental activities, when the evaluation steps described in § 404.1520(e) or (f)(1) apply.

Assistance From a Disability Attorney

An experienced disability attorney can assist you in gathering the above medical records and opinions from your treating medical providers to represent you in your disability claim. Mr. Ortiz is a Board Certified Social Security Disability Attorney with experience in handling hundreds of SSDI and SSI disability claims.  Call today at 850-898-9904 for a free case evaluation.