TN 23 (03-17)

DI 22505.007 Developing Evidence from Medical Sources

A. Request medical evidence

We request medical evidence from each medical source that the claimant identifies as having evaluated, examined, or treated him or her. For the definition of medical source, see DI 22505.001 Medical and Nonmedical Evidence.

For general instructions on requesting medical evidence, see DI 22505.006 Requesting Evidence - General.

For a suggested model letter to use when requesting medical evidence of record in adult claims, see NL 00705.770 Model Letter Requesting Medical Evidence of Record (MER).

B. Content of medical evidence

Medical evidence should include:

  • Medical history

  • Objective medical evidence (medical signs, laboratory findings, or both)

  • Prescribed treatment and claimant’s response to the treatment

  • Diagnosis and prognosis

  • Medical opinion

NOTE: You are not required to follow-up with a medical source solely to obtain a medical opinion. For additional information about follow-up requests for MER, see DI 22505.035 Follow-up Requests for Medical Evidence of Record (MER).

C. When to request a medical opinion

Generally, we request a medical opinion, along with medical evidence, through a request for medical evidence. Request a medical opinion from all of the claimant’s medical sources with the exception of the following situations or sources:

  • In statutory blindness cases.

  • From a laboratory.

  • From an entity, that maintains a medical source’s records, such as a hospital or a clinic.

  • From a medical source who previously refused to provide medical opinions for all of his or her patients.

  • From a Department of Veterans Affairs (VA) facility. (As a matter of policy, the VA does not permit its physicians and psychologists to provide this type of opinion statement.) For additional information, see DI 22505.022. Developing Medical Evidence of Record (MER) from the Department of Veterans Affairs (VA) Veterans Health Administration (VHA) Medical Facilities.

  • From the National Personnel Records Center. For additional information, see DI 22505.024 Developing Evidence from the Office of Personnel Management.

Document all disability development undertaken on the case development summary worksheet. For details, see DI 20503.001.E. Documenting the Disability Folder – Disability Determination Services (DDS).

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DI 22505.007 - Developing Evidence from Medical Sources - 03/24/2017
Batch run: 08/17/2017