615. Medical and Other Evidence

615.1 What should medical evidence include?

1. We need evidence from an acceptable medical source to establish whether you have a medically determinable impairment. These sources are:

   • Licensed physicians (medical or osteopathic doctor);

   • Licensed or certified psychologists - Included are school psychologists, or other licensed or certified individuals with other titles who perform the same function as a school psychologist in a school setting, for purposes of establishing mental retardation, learning disabilities, and borderline intellectual functioning only;

   • Licensed optometrists, for purposes of establishing visual disorders only (except, in the U.S. Virgin Islands, licensed optometrists, for the measurement of visual acuity and visual fields only);

   • Licensed podiatrists, for impairment(s) of the foot, or foot and ankle only, depending on whether the State in which the podiatrist practices permits the practice of podiatry on the foot only, or the foot and ankle; and

   • Qualified speech-language pathologists, for purposes of establishing speech or language impairments only.

2. Medical reports should include:

   • Medical history;

   • Clinical findings (such as the results of physical or mental status examinations);

   • Laboratory findings (such as blood pressure, X-rays);

   • Treatment prescribed with response;

   • Diagnosis;

   • Prognosis; and

   • A statement from the acceptable medical source, based on the above elements, about what you can still do despite your impairment(s)

   NOTE: This evidence is not needed in blindness claims.

For adults, the statement should describe your ability to do work-related functions, such as sitting, standing, or moving about, lifting, carrying, handling objects, hearing or speaking, and, in cases of mental impairment, the medical source's opinion about your ability to understand, to carry out and remember instructions, and to respond appropriately to supervision, coworkers, and work pressures in a work setting.

For a child filing for SSI, the statement should also describe how the child's condition limits his or her ability to function in daily activities compared to that of children the same age who do not have impairments. Activities may involve acquiring and using information, attending and completing tasks, interacting and relating with others, moving about and manipulating objects, caring for himself or herself, and health and physical well-being.

615.2 Other sources of evidence

In addition to medical evidence from acceptable medical sources (§615.1), we may use evidence from other sources to show the severity of your impairment and how it affects your ability to work. Other sources include medical sources not listed in §615.1, such as nurse practitioners, physician assistants, chiropractors, and therapists, as well as non-medical sources, such as your spouse, relatives, neighbors, and friends.

Last Revised: Apr. 2, 2007