What is included in a consultative examination report?

Consultative Exam Paperwork for Social Security DisabilityDisability Determination Services (DDS) requested that you get a consultative exam. You complied with the request because you knew that the consultative exam was essential to your Social Security disability determination. Now, however, you may wonder what will be included in the consultative exam report.

Required Consultative Exam Report Content

The Social Security Administration’s Consultative Examination Guide, also known as the Green Book, requires consultative exam reports to include at least the following content:

  • The applicant’s Social Security number (or other case identifier)
  • Whether the applicant provided a photo ID
  • A physical description of the applicant
  • The applicant’s current medical history including symptoms, history of the start of the condition and its progression, treatment, and impact on daily living activities
  • The applicant’s past medical history, including things such as significant illnesses, injuries, and treatments
  • A list of the applicant’s current medications
  • A review of the applicant’s body systems and how the condition has or has not impacted them
  • The applicant’s social history, including alcohol use, tobacco use, and drug use
  • The applicant’s family history
  • A description of the physical examination conducted by the doctor
  • An interpretation of lab results for any tests conducted
  • The results of imaging tests, if authorized by DDS
  • Medical source statement that assesses the applicant’s abilities and limitations based on the applicant’s medical condition. In this section, the doctor should explain the medical condition that prevents the applicant from working. Some of the specific things the doctor should include are the applicant’s ability to lift, stand, sit, stand, walk, carry, push, pull, and other factors that would impact the applicant’s ability to work.

Once the report is complete, the doctor who performed the exam should review and sign it. The doctor is responsible for the report’s contents. DDS will reject any report that is unsigned, signed with a disclaimer such as “dictated but not read,” rubber-stamped but not signed, or signed by someone other than the doctor.

Additional Consultative Exam Report Content for Specific Disabilities

Specific types of disabilities require additional information. For example, consultative exam reports require specific details about things such as diagnostic procedures, physical exams, symptoms, and more for the following types of conditions:

  • Musculoskeletal injuries
  • Visual impairments
  • Hearing impairments
  • Respiratory system conditions
  • Cardiovascular system conditions
  • Digestive system disorders
  • Genitourinary impairments
  • Hematological disorders
  • Skin disorders
  • Endocrine disorders
  • Neurological disorders
  • Mental disorders
  • Malignant neoplastic diseases
  • Immune system disorders

The goal of all of this information is to help DDS decide whether you are disabled and whether you qualify for Social Security disability benefits. Overall, the consultative report should explain your disability in enough detail for DDS to thoroughly understand how it impacts your life, how it affects your ability to work, and how long it is expected to last.

You can help the doctor complete a full consultative exam report by being honest and cooperative. If you need an interpreter with you during the exam, then an interpreter should be provided to you at no cost so that the exam and resulting report are thoroughly and accurately completed.

Incomplete consultative exam reports may be sent back to the doctor, and a determination on your Social Security disability application may be delayed until all the required information is provided to DDS.

What Happens After You Receive a Consultative Exam Report

Once a complete and signed consultative exam report is provided to DDS, the report should be considered by DDS and DDS should make a determination about your Social Security disability eligibility.

While your consultative exam report is important to your disability determination, it is not the only factor that will be considered.

Contact an experienced Social Security disability lawyer today to discuss your application and the necessary steps to getting your disability application approved. Our Massachusetts Social Security disability lawyers would be pleased to provide you with a phone consultation. You don’t have to travel to our Natick office to get the disability benefits that you deserve. Call us today to learn more.

 

John L. Keefe
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Founding Attorney, Massachusetts Social Security Disability Lawyer