Sample Physician-To-Ssa Letter Template - Physical Impairment printable pdf download

Sample Physician-to-SSA Letter

This sample letter is designed as a guide to help you draft a

personalized medical report documenting physical impairment.

[Doctor’s Name] [Street Address] [City, ST ZIP] [DATE]

[Recipient Name] [Title] [Company Name] [Street Address] [City, ST ZIP]

Re: [Patient Name; Date of Birth; SSN]

To Whom It May Concern:

My patient

[NAME]

has

[MS diagnosis and relevant condition]

that is severe.

[HE or SHE]

limited in daily activities and is unable to work on a sustained basis. My findings have been

confirmed through physical examination, medical history, magnetic resonance imaging, and

standard neurological examination, including evaluations of strength, spasticity,

coordination, gait, sensation, vision, and mental status.

[NAME’s]

symptoms include

[FULL

LIST OF SYMPTOMS AND ANY ASSISTANCE

DEVICES].

Describe the severity of the MS diagnosis, onset of symptoms, the course and nature of

the condition, and side effects of treatment over time. Reference medical evidence.

Include details of all impairments related to MS, the progression and severity of

impairments and any related symptom(s), and all other conditions,

making specific

reference to the SSA criteria for evaluating

impairment.

Reference medical records you are submitting to SSA, but don’t duplicate the

information here. Include clinical and laboratory findings and a detailed information on

the claimant’s ability to function. Describe the medical history, specific tests used, lab

results, and relevant clinical findings. Include that the individual is compliant with

prescribed medical treatments.

Detail how physical, visual, and cognitive impairments impact the person’s ability to

participate in daily activities and work on a sustained basis. Reference restrictions on

sitting, standing, walking, extremity use, concentration, memory, persistence, or pace.

Always report fatigue and its limited impact. Because fatigue is difficult to measure

objectively, provide any supporting evidence you have.

In my opinion,

[NAME]

is unable to resume any type of gainful employment due to physical

impairment. MS is a progressive neurological disorder, and while disability can be delayed

with treatment, there is not a cure. My expectation is that

[NAME]

will see a continued

decline in function over time.

Sincerely,

Sample Physician-To-Ssa Letter Template - Physical Impairment

Related Articles

Related forms

Related Categories