Disability Incapacity Checklist and Sample Doctor Letters

Discussion in 'Fibromyalgia Main Forum' started by shinlee, Feb 7, 2005.

  1. shinlee

    shinlee New Member


    This is a page linked from a website that deals with multiple pain issues.

    Hope it helps someone.

    Take care.


    The Massachusetts CFIDS Association Disability Handbook
    Copyright©1994 Kenneth S. Casanova

    Incapacity Checklist

    The following Incapacity Checklist is taken from How to Secure and Protect Your Social Security Disability Benefits, published by the Mass. Disability Law Center.
    This checklist can assist your doctor in evaluating your inability to work. You can give a copy of this checklist to your doctor along with the DDS Instructions.

    How does your condition affect:

    your daily activities your ability to stand, sit, or walk for a long period
    your ability to lift or carry weight
    your ability to understand, carry out, and remember instructions
    your ability to respond appropriately to your supervisor and co-workers
    other physical or psychological functional restrictions, and
    your ability to adjust to the stress of a work environment

    Sample Doctors' Letters

    Security to document patients' CFS disability claims.

    These letters are provided to help show how a doctor's letter should be written and the type of information it should contain in order to make the letter strong and effective.

    Please read the explanations of each letter carefully, since although two of the letters are relatively strong, each of the two letters lacks certain important information. By studying each letter and the letter's instructions, you will know the strengths and weaknesses of each, thereby giving you and your doctor a good idea of what a model letter should contain.

    For purposes of comparison, the selection also includes the type of weak letter (which all too often is the type of letter submitted) that would not be effective in securing disability benefits.

    Note: The sample letters should only be used as a supplement to the DDS Instructions. The Instructions are the best guide to doctors for preparing the medical letter.


    Explanation to Letter #1
    Letter #l is a good example of the type of letter that would be effective in establishing a CFS patient's eligibility for Social Security disability. It adequately documents the patient's CFS diagnosis by providing the necessary detailed review of symptoms and symptom history. The letter also states that the patient's depression is result of the CFS rather than the cause of the CFS symptoms.

    The letter also provides the required assessment of the patient's inability to work and to perform various tasks and activities.

    The doctor's statement that the patient is 100% disabled and unable to work is especially strong.

    While this letter represents a good medical report, an even stronger report would provide more detail on the patient's inability to perform a variety of daily tasks; the letter should also include an evaluation of the patient's capacity for lifting, walking, sitting, and standing.

    The letter would also be stronger if it included the results of diagnostically relevant laboratory tests. With these suggested additions, Letter #l would be an excellent medical report.

    Letter #1

    To Whom It May Concern:

    I am writing to you to reiterate my conclusion that (______) is suffering from a disabling illness and is l00% disabled. (______) suffers from Chronic Fatigue Syndrome. To reiterate, she has undergone extensive medical, immunologic and physical examinations. Further neuropsychological testing will take place next month with Dr. (______). (______) has the characteristic symptoms of the syndrome, i.e., severely disabling fatigue, malaise, myalgias, lethargy, weakness, nausea, dizziness, low grade fever, joint pain, sore throats, swollen glands, headaches, mental confusion, memory loss and impaired ability to concentrate. Since my last letter, (______) has described intensification of problems with memory, concentration, headaches, generalized weakness and fatigue. She continues to be under considerable psychological distress that is greatly exacerbated by her tenuous financial situation. Secondary depression that is a result of her long-term illness is also worrisome. (______) is currently taking amitriptyline as a joint therapy for that as well as for her sleep disorder and myalgias.

    At present, restricting activity is the only way to prevent exacerbation of CFS symptoms. (______) is 100% disabled. She is capable of only mild intermittent activity. Her ability to sustain any activity for even a few hours a day is unpredictable. Any prolonged activity (even sedentary) worsens her condition and can cause exacerbation of her symptoms. Therefore, her activities of daily living are markedly limited as is her ability to complete tasks. This illness has radically limited (______)'s life. She has been unable to maintain work at any level and her social life is virtually nil.

    (______)'s physical symptoms have exacerbated since my last letter to your office and this illness has proved to be emotionally devastating. She is 100% disabled at this time. Work for her is totally out of the question.

    I will continue to follow (______) to investigate therapies to counteract the devastating illness.

    If I can be of any further help in support of her application for disability benefits, please do not hesitate to contact me.

    Sincerely, (______)

    Note: A good alternative to the above procedure is simply to ask your doctors to send you copies of all records that they send to Social Security. This way, you will at least know what has been sent and will have copies for your own records.
  2. shinlee

    shinlee New Member

    more info to help those seeking disability.
  3. silky17

    silky17 New Member

    Thank you for taking the time to post this info. I wish I could give it the Dr. But I am not sure he would take that well. I suppose I am just going to have to suffer with alot more flares and loss if income due to this DD. Thanks again ...........

  4. opalgem

    opalgem New Member

    Thank You shinlee. I am about to be fired for all of the reasons stated above. I am at wits end with no where to turn. I guess disability is my only alternative. This DD has beaten me. Your post has opened my eyes. Thanks again.
  5. Lily Silver

    Lily Silver Member

    There are some more great sample letters here:

    Lotus’ Letter – A truly excellent letter. Includes a detailed chart that provides a complete medical description of how and why she cannot function and work, plus excellent information on medical evidence. For Lyme Disease and Chronic Fatigue Syndrome.

    RFC Forms – Many people do not get a letter from their doctor, they get an RFC form instead. A lot of doctor’s letters are too simple and do not include the specific information Social Security needs. An RFC form includes every question Social Security needs to know about your ability to function.

    Connie’s Lyme Disease Letter includes guidelines for a physician plus a sample letter.

    Tulip’s Chronic Fatigue Syndrome Letter – Letter used for LTD appeal.

    Zinnia’s Chronic Fatigue Syndrome Letter – Includes all the information from the Social Security Ruling on Chronic Fatigue Syndrome.

    Rosemary’s Medical Outline – An outline you can create based on your medical records. Helpful to give to a doctor and to submit to SSA.

    Carnation’s Medical Outline – Another really excellent outline!
    Last edited: Mar 11, 2018