TN 4 (09-15)

DI 24501.002 Introduction to Medical Evaluation

Citations: 42 U.S.C. 421(h); 42 U.S.C. 1382c(a)(3)(H) and (I);

20 CFR 404.1503(e)/ 416.903(e) and (f); 404.1520a(d)(1)/416.920a(d)(1); 404.1526/416.926; 416.926a(c); 404.1527(f)(1)/416.927(f)(1); 404.1614/416.1014; 404.1615(c) and (d)/416.1015(c), (d), and (e); and 404.1616/416.1016

A. Policy for medical evaluation

The medical evaluation is the agency explanation of the medical determination.

Every disability determination must contain a medical evaluation unless the case contains no medical evidence. This medical evaluation must be contained on one or more medical assessment forms and should address the alleged impairments for the full assessment period depending on the nature of the impairments.

B. Requirements for medical evaluation

1. Assessment period covered

Generally, the medical evaluation should cover the time from potential onset date (POD) or alleged onset date (AOD) through the date of adjudication. You may have to evaluate more than one period to document changes over time or to establish whether a disabling level of severity is expected to last 12 months.

Factors that could impact the assessment period include:

  • A date last insured (DLI) in the past

  • A closed period of disability

  • A prescribed period or controlling date for Disabled Widow Benefit claims

  • Establishing disability onset prior to the attainment of age 22 for TII Childhood Disability Benefits (CDB)

2. Issues addressed

The medical evaluation is the agency explanation of the medical determination.

a. Medical evaluation(s) must:

  • address all allegation(s)

  • address all medically determinable impairment(s) (MDI(s))

  • discuss signs, symptoms, and laboratory findings

  • contain an analysis of the medical evidence and how it was used in the evaluation

b. If applicable, discuss:

  • medical opinions

  • collateral source evidence about function

  • evaluation of symptoms

  • duration or expected duration

  • adherence to or failure to follow prescribed treatment

  • drug addiction and alcoholism (DA and A)

NOTE: Adjudicators may process a fully favorable allowance determination without addressing all of these issues if the claimant meets the medical or medical and vocational criteria for disability, including duration, and the Established Onset Date (EOD) is fully favorable.

C. Documenting the medical evaluation

Complete the medical evaluation on SSA-approved medical assessment form(s).

Disability Determination Services (DDS) adjudicators, including medical consultants (MCs) and psychological consultants (PCs), generally complete medical assessment forms in the electronic Claims Analysis Tool (eCAT). For additional guidance on completing medical assessment forms in eCAT, see the most recent eCAT User Guide. These forms are also available for stand-alone use as an eform in the form selector application.

1. SSA-approved medical assessment forms

  • SSA-2506-BK (Psychiatric Review Technique)

  • SSA-4734-BK (Physical Residual Functional Capacity Assessment)

  • SSA-4734-F4-SUP (Mental Residual Functional Capacity Assessment)

  • SSA-538-F6 (Childhood Disability Evaluation Form)

  • SSA-416 (Medical Evaluation)

2. Signature Requirements

Each medical assessment form must be signed by the proper individual with an acceptable physical signature or an SSA-approved electronic signature. Only the following individuals may sign medical assessment forms: