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Your professional, well-documented assessment of a patient’s functional limitations is key to a successful disability determination.

Fam Pract Manag. 2024;31(1):19-24

This content conforms to AAFP criteria for CME.

Author disclosures: no relevant financial relationships. No actual patient names have been used.

Paperwork pertaining to patient disability is a time-consuming, difficult, and often wearisome process for primary care physicians and other providers. The difficulty has its foundation in the multiple disability types, varying documentation requirements, and differences in who serves as the final arbiter of disability. The aim of this article is to review individual cases and, utilizing a step-wise framework,1 provide examples of how to efficiently, accurately, and confidently complete various types of disability paperwork to aid patients in their disability applications.

KEY POINTS

  • When reviewing disability applications, insurance representatives, judges, and lawyers rely heavily on the physicians’ assessments of functional limitations due to medical conditions.

  • Physicians can strengthen their supporting documentation by following certain best practices, such as being specific in describing diagnoses and using objective measures as much as possible.

  • The four-step framework cited in the article can help increase the likelihood of a successful application.

OVERVIEW

It is common for patients to come to the primary care office with some sort of disability question or concern. Many people request Family and Medical Leave Act (FMLA) paperwork be completed for their employer in order to take some time off of work due to illness or accident, or to take care of a family member.2 For long-term and short-term disability, the physician’s assessment and supporting documentation can facilitate insurance determinations through processes established by private insurance companies and workers’ compensation claims, whereas Social Security disability determination is specifically and only the prerogative of the Social Security Administration judge.

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