In addition to a free blank Physical Capacity Evaluation form, we also offer a free blank Medical Source Statement (Mental) form (sometimes called a Residual Functional Capacity Assessment form or RFC). The RFC is a questionnaire for your mental health doctor to fill out concerning the limitations and impairments you have as a result of your mental impairments.
Aside from the actual medical records from your claim, one of the absolute best pieces of evidence you can have is a Medical Source Statement from your treating doctor.
As I explain to my own clients, your medical records identify what your medical diagnoses are. However, the medical records do not necessarily indicate how you are now limited due to your medical conditions. For example, your medical records may note your diagnosis of severe depression, anxiety and/or PTSD. However, the medical records may not indicate that you will have difficulty in:
- understanding, carrying out, and remembering instructions;
- interacting appropriately with co-workers, supervisors and the general public;
- staying on task without too many distractions;
- completing tasks in a timely manner; and
- responding to normal work pressures and and dealing with stresses in a routine work setting.
The medical records simply may not indicate that you are going to be severely restricted in above ways given your mental health condition. That’s where the Medical Source Statement comes in. The MSS is designed for your medical provider to “bridge the gap” between the diagnoses in your medical records and the resulting impairments you have.
Keep in mind that these assessments are not required in any case. Yet, the assessments carry great weight because they allow the Judge or adjudicator reviewing your claim to get a better idea of your restrictions and limitations.
They are also useful in examining the vocational expert who may be testifying at the hearing in your disability claim. Let’s assume that your doctor notes in the MSS that you will be easily distracted and that you cannot maintain concentration for two hours at a time; and that you will miss more than 4 days a month due to severe depression. If you ask the vocational expert if there are many jobs that will permit such limitations, the VE is likely to respond that there are not many jobs that will accommodate such limitations.
Free Medical Source Statement Form Mental
Download a free PDF of a 4-page Medical Source Statement of Ability to Do Work-Related Activities (Mental):
- Download PDF (right click, save as)