Will psychotherapy notes be considered if I apply for Social Security disability?

Doctor Writing Down Psychotherapy NotesYou know what’s going on with your health. You know that your physical or mental condition prevents you from working. However, before you receive Social Security disability benefits, you have to convince the Social Security Administration that you are disabled.

You Will Need Medical Evidence

The Social Security Administration is not going to find you eligible for Social Security disability benefits just because you say that you are disabled. Instead, you must provide evidence to convince the Social Security Administration that you meet the requirements of a disability described in the Listing of Impairments, your disability is just as bad as one of the conditions in the Listing of Impairments, or you can’t work because of your disability.

Some of the most important pieces of evidence that you must provide are medical evidence. The specific medical evidence depends on the nature of your disability. For example:

  • If you have cancer, then medical records from your oncologist may be crucial
  • If you have a heart condition, then medical records from your cardiologist may be essential
  • If you have a mental health condition, then medical records from your psychologist or psychiatrist may be critical to your disability determination

While you may be willing to share the details of your diagnosis, treatment plan, and prognosis with the Social Security Administration, you may be reluctant to share your psychotherapy treatment notes with anyone.

What Are Psychotherapy Notes?

According to the federal Health Insurance Portability and Accountability Act (HIPAA), psychotherapy notes include notes recorded in any way by a mental health professional that document or analyze the contents of conversation during a private counseling session or a group, joint, or family counseling session. These notes must be separate from the rest of an individual’s medical record.

However, psychotherapy notes do not include medication prescription and monitoring, the start and stop times of counseling sessions, the modalities and frequencies of treatment, clinical test results, or summaries of diagnosis, functional status, treatment plan, symptoms, prognosis, or progress. Instead, psychotherapy notes are limited to the therapist’s documentation or analysis of private conversations.

Psychotherapy Notes Are Not Medical Evidence

The Social Security Administration’s guidance to healthcare professionals about psychotherapy notes is clear. The agency states explicitly, “Social Security recognizes the sensitivity and extra legal protections that concern psychotherapy notes (also called “process” or “session” notes) and does not need the notes.”

The Social Security Administration goes on to provide three options for mental health professionals. Mental health professionals who keep psychotherapy notes may:

  • Send medical records without psychotherapy notes, if psychotherapy notes are kept separate from medical records.
  • Disclose all records, including psychotherapy notes, if psychotherapy notes are not kept separate from other parts of the medical record. Alternatively, the medical provider may choose to blackout or remove parts of the record that would be considered psychotherapy notes and could be kept separately by the mental health provider.
  • Prepare a special report describing in detail the critical current and longitudinal aspects of the patient’s treatment and functional status.

Your Social Security disability will advise you about the evidence needed to establish eligibility.

Protect Your Privacy and Your Social Security Disability Eligibility

You shouldn’t have to choose between protecting the privacy of your therapy notes and receiving Social Security disability benefits. Instead, we invite you to contact our experienced Social Security disability lawyers today for a free phone screening about your Social Security disability eligibility.

If you qualify for Social Security disability, then our lawyers will gather all of the relevant evidence, complete your application, and advocate on your behalf throughout the eligibility process. The majority of initial Social Security disability applications are denied, and we can help you avoid preventable errors that prevent you from getting the benefits you’ve earned. Call us or complete our online contact form if you are applying for Social Security disability in New Hampshire, Rhode Island, or Massachusetts and let’s talk about your rights and how we can help you.

 

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