Lee Ann Torrans
Social Security Disablity Law
6532 LBJ Freeway
Dallas, Texas 75240

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Downloadable RFC Forms

Childhood RFC Mental Impairment: Autism

Childhood Autism RFC in PDF
Childhood Autism RFC in Word

Childhood RFC Mental Impairment: ADD – ADHD

Childhood ADD or ADHD RFC in PDF
Childhood ADD or ADHD RFC in Word

Childhood RFC Mental Impairment: Anxiety Disorder

Childhood ADD or ADHD RFC in PDF
Childhood ADD or ADHD RFC in Word

Childhood RFC Mental Impairment:  Schizophrenia, Psychotic

Childhood Schizophrenia or Psychotic in PDF
Childhood Schizophrenia or Psychotic in Word

What is Residual Functional Capacity

RFC stands for “residual functional capacity.” In an RFC assessment a professional evaluates the claimant’s functional capacity and documents that to the best of their ability. The mental or physical disability is considered in the award decision in terms of the claimant’s ability to function in their employment.

As you read through the complexities and variations of the requirements for a mental RFC and the documentation required you may begin to understand why these claims are so difficult and so many are turned down. Have the right information, documentation and supporting RFC is complicated, even for attorneys.

You May Require Several RFC Forms.

A mental RFC addresses affective mental disorders.

Other impairments and limitations resulting from a combination of impairments should be documented separately.

The SSA states it in this way: “RFC is a multidimensional description of the work-related abilities you retain in spite of your medical impairments.” Another way of putting it is, even though you have a disability can you still work? The RFC is the bridge between your disability and your ability to work. It ties your disability and its impact upon your life to your inability to work in a very concrete fashion and in terms and by standards that the SSA accepts.

Crucial SSG Ruling to Review Before Preparing RFC Form

It is crucial to review this ruling before preparing your RFC Form.

http://www.socialsecurity.gov/OP_Home/rulings/di/01/SSR85-16-di-01.html

Winning an award based on a mental impairment alone is extremely difficult. Without a detailed RFC Form supported by extensive and documented treatment, it is virtually impossible. The mental conditions listed by the Social Security Administration are found here.

The categories of SSA listed mental disorders is extensive. The first place to begin in the preparation of a Mental RFC is with the diagnosis at issue.

12.01 Category of Mental Impairments
12.02 Organic Mental Disorders
12.03 Schizophrenic, paranoid and other psychotic disorders
12.04 Affective disorders
12.05 Mental retardation
12.06 Anxiety-related disorders
12.07 Somatoform disorders
12.08 Personality disorders
12.09 Substance addiction disorders
12.10 Autistic disorder and other pervasive developmental disorders


Test: Has Your Ability to Work Been Impacted

Just as with a physical impairment or physical disability the issue is NOT whether you have an impairment or a disability. The issue is whether this impairment or disability impacts your ability to work. The form below is simply a starting point. It is crucial that your specific impairments be documented WITH an explanation of how your impairment impacts your ability to work. We are in the process of developing a detailed from for each mental impairment category identified above.

Mental RFC Form

A mental RFC form evaluates the claimant’s mental symptoms.

Generally, a Claimant’s RFC assessment will address these issues:

Poor memory
Decreased energy
Illogical thinking
Ability maintain concentration and attention
Ability to interact socially in work settings
Ability to assimilate new information
Ability to successfully engage in simple, routine, repetitive tasks

RFC forms completed by a treating physician with a long term relationship with the claimant can be more thorough than a psychologist’s assessment and serve as an important addition to the evaluation process.

Presenting an RFC from for your personal physician, or treating physician, who has known you for an extended period of time may provide a more fair assessment.

Reports Should Contain the Following

Reports from psychiatrists and other physicians, psychologists, and other professionals working in the field of mental health should contain specific information including:

The individual’s mental ability shoud be documented to include:

Medical history

Mental status evaluation

Psychological testing

Diagnosis

Treatment(s) prescribed and

Response to that treatment(or those treatments)

Prognosis

Description of the individual’s daily activities, and

Medical assessment describing ability to do work-related activities

These reports may also contain other observations and opinions or conclusions on such matters as the individual’s:

Ability to cope with stress,

Ability to relate to other people, and

Ability to function in a group or work situation.

(See: http://www.socialsecurity.gov/OP_Home/rulings/di/01/SSR85-16-di-01.html)

The “Treating Physician” Rule

Because your treating physician has a long term relationship with the claim the SSA gives substantial weight their opinion. It is reasonable to assume this physician is in a substantially closer relationship to the claimant and more informed regarding the claimant’s condition.

It is very important for their opinion to be properly documented in comprehensive RFC forms that clearly states why a claimant’s various medical problems make a return to work impossible and are consistent with a claimant’s medical evidence.

Licensed M.D. or D.O.: Only a licensed M.D. or D.O., preferably a psychiatrist may interpret tests which include a medical diagnosis of a brain or interpret tests crucial to the diagnosis such as neuroimaging.

Licensed Ph.D.: A licensed Ph.D.-level clinical psychologist experienced in the evaluation of affective disorders may address issues that do not include medical diagnosis. Often it is the Ph.D. that more fully understands the impact upon the life and the ability to function that the claimant has experienced. For this reason two RFC forms on this one topic may be required. First, the form from the M.D. or D.O. and then secondly, the treating Ph.D.

RFC Forms Interpret Medical Records

  • An RFC interprets medical records with an assessment of the claimant’s ability to work.
  • The M.D. or D.O. may provide the medical diagnosis of a brain or interpret tests crucial to the diagnosis such as neuroimaging
  • The treating Ph.D. may provide the impact upon the life of the claimaint
  • Symptoms and test results should always be interpreted for the benefit of the examiner.

Purpose and Benefit of RFC Forms

  • RFC forms interpret the medical records
  • This professional interpretation of the medical evidence explains the data
  • The physician can specifically address a claimant’s limitations

DO NOT GO TO A HEARING WITHOUT A RECENT RFC FORM THAT ADDRESSES YOUR SPECIFIC ISSUES – WHETHER YOU ARE REPRESENTING YOURSELF OR YOU HAVE AN ATTY.

IF YOU HAVE AN ATTY YOU SHOULD HAVE AN RFC FORM SPECIALLY DRAFTED TO ADDRESS YOUR PHYSICAL LIMITATIONS AS THEY PERTAIN TO YOUR ABILITY TO WORK.

Medically Documented Findings Included: Be certain that the required medically documented findings are included in both the medical records and identified in the RFC Form.

Document the Restrictions Identified in Listed Category: Under the specific category enumerated you will find a statement which indicates that “at least two” of these restrictions. For example under the category of Bi-Polar Disorder which is found under “12.04 Affective Disorders” the findings must include:

B. Resulting in at least two of the following:

1. Marked restriction of activities of daily living; or

2. Marked difficulties in maintaining social functioning; or

3. Marked difficulties in maintaining concentration, persistence, or pace; or

4. Repeated episodes of decompensation, each of extended duration;

Be certain that your RFC Form indicates at least two of those stated limitations and the medical records document that limitation.

A Mental RFC Form Documents What the Claimant Can Still Do Despite Mental Impairment(s)

 

Name: __________________________ Social Security No. ________________________

Please answer the following questions concerning your patient’s impairments.

1. Frequency and length of contact:

a. When did the patient first present to you with these symptoms

b. An affective disorder is defined by the 2008 SSA Bluebook as:

Characterized by a disturbance of mood, accompanied by a full or partial manic or depressive syndrome. Mood refers to a prolonged emotion that colors the whole psychic life; it generally involves either depression or elation.

c. Has your patient been diagnosed with an “affective disorder” as defined above?

d. Specifically which affective disorder(s) applies to your patient.

1. How was this determination regarding the diagnosed disorder made:

Specific administered testing – identify test and results

Mental Examination

Anecdotal Information

2. For each abnormality identified provide a detailed description of the abnormality in terms of nature, frequency, and duration.

3. The most recent date you are personally aware such abnormality was present.

4. Describe the patients historical response to medication or other therapy during the progress of your treatment

2. DSM-IV Multitaxial Evaluation:

Axis I _____________________________ Axis IV: _______________________________
Axis II ____________________________ Axis V: Current GAF: ______________________
Axis III ___________________________ Highest GAF past year: _____________________

Identify which of these conditions applies to your patient:

The required level of severity for these disorders is met when the requirements in both A and B are satisfied, or when the requirements in C are satisfied.

A. Medically documented persistence, either continuous or intermittent, of one of the following:

1. Depressive syndrome characterized by at least four of the following:

a. Anhedonia or pervasive loss of interest in almost all activities; or

b. Appetite disturbance with change in weight; or

c. Sleep disturbance; or

d. Psychomotor agitation or retardation; or

e. Decreased energy; or

f. Feelings of guilt or worthlessness; or

g. Difficulty concentrating or thinking; or

h. Thoughts of suicide; or

i. Hallucinations, delusions, or paranoid thinking; or

2. Manic syndrome characterized by at least three of the following:

a. Hyperactivity; or

b. Pressure of speech; or

c. Flight of ideas; or

d. Inflated self-esteem; or

e. Decreased need for sleep; or

f. Easy distractibility; or

g. Involvement in activities that have a high probability of painful consequences which are not recognized; or

h. Hallucinations, delusions or paranoid thinking; or

3. Bipolar syndrome with a history of episodic periods manifested by the full symptomatic picture of both manic and depressive syndromes (and currently characterized by either or both syndromes);

AND

B. Resulting in at least two of the following:

1. Marked restriction of activities of daily living; or

2. Marked difficulties in maintaining social functioning; or

3. Marked difficulties in maintaining concentration, persistence, or pace; or

4. Repeated episodes of decompensation, each of extended duration;

OR

C. Medically documented history of a chronic affective disorder of at least 2 years’ duration that has caused more than a minimal limitation of ability to do basic work activities, with symptoms or signs currently attenuated by medication or psychosocial support, and one of the following:

1. Repeated episodes of decompensation, each of extended duration; or

2. A residual disease process that has resulted in such marginal adjustment that even a minimal increase in mental demands or change in the environment would be predicted to cause the individual to decompensate; or

3. Current history of 1 or more years’ inability to function outside a highly supportive living arrangement, with an indication of continued need for such an arrangement.

4. Describe the clinical findings in you answers in number 3, immediately preceeding, include results of mental status examination which demonstrate the severity of your patient’s mental impairment and symptoms.

5. Identify your patient’s signs and symptoms:

a. Poor memory
b. Appetite disturbance with weight change
c. Sleep disturbance
d. Personality change
e. Mood disturbance
f. Emotional lability
g. Loss of intellectual ability of 15 IQ points or more
h. Delusions or hallucinations
i. Substance dependence
j. Recurrent panic attacks
k. Anhedonia or pervasive loss of interests
l. Psychomotor agitation or retardation
m. Paranoia or inappropriate suspiciousness
n. Feelings of guilt/worthlessness
o. Difficulty thinking or concentrating
p. Suicidal ideation or attempts
q. Oddities of thought, perception, speech or behavior
r. Perceptual disturbances
s. Time or place disorientation
t. Catatonia or grossly disorganized behavior
u. Social withdrawal or isolation
v. Blunt, flat or inappropriate affect
w. Illogical thinking or loosening of associations
x. Decreased energy
y. Manic syndrome
z. Obsessions or compulsions
aa. Intrusive recollections of a traumatic experience
bb. Persistent irrational fears
cc. Generalized persistent anxiety
dd. Somatization unexplained by organic disturbance
ee. Hostility and irritability
ff. Pathological dependence or passivity

Other symptoms and remarks:

6. Are your patient’s impairments reasonably consistent with the symptoms and functional limitations described in this evaluation?

Yes ______ No______

If no, please explain:

7. Medications

a. List prescribed medication and dosage Daily Amount Taken and describe medications discontinued

b. Describe any side effects of medications which may have implications for working, e.g. dizziness, drowsiness, fatigue, lethargy, stomach upset, etc:

8. Does your patient have a low I.Q. or reduced intellectual functioning?

Yes ______ No______

Please explain (with reference to specific test results):

9. On the average, how often do you anticipate that your patient’s impairments or treatment would cause your patient to be absent from work?

Never ___ Less than once a month ___ About once a month___

About twice a month ___ About three times a month ___ More than 3 times a month___

Independent of any impairment from alcoholism and/or drug addiction, please rate the individual’s capabilities to perform the following basic mental activities of work on a regular and continuing basis. “Regular and continuing basis” means 8 hours a day for 5 days a week or an equivalent work schedule.

No/mild loss No significant loss of ability in the named activity; can sustain performance for 2/3 or more of an 8-hour workday.

Moderate loss Some loss of ability in the named activity but still can sustain performance for 1/3 up to 2/3 of an 8-hour workday.

Marked loss substantial loss of ability in the named activity; can sustain performance only up to 1/3 of an 8-hour workday.

Extreme loss Complete loss of ability in the named activity; can not sustain performance during an 8-hour workday.

10. Is your patient’s ability to understand, remember and carry out instructions affected by the impairment?

Yes _____No_____

If “no”, go to next question. If “yes”, please check the appropriate block to described the individual’s ability to perform the following work-related mental activities:

For each item listed below indicate one of the following:

a. Remember locations and work-like procedures:

No — Mild Loss —- Moderate Loss —- Marked Loss —- Extreme Loss

b. Understand and remember very short, simple instructions:

No — Mild Loss —- Moderate Loss —- Marked Loss —- Extreme Loss

c. Carry out very short, simple instructions:

No — Mild Loss —- Moderate Loss —- Marked Loss —- Extreme Loss

d. Understand and remember detailed instructions:

No — Mild Loss —- Moderate Loss —- Marked Loss —- Extreme Loss

e. Carry out detailed instructions:

No — Mild Loss —- Moderate Loss —- Marked Loss —- Extreme Loss

f. Maintain attention and concentration for extended periods, i.e. 2 hour segments:

No — Mild Loss —- Moderate Loss —- Marked Loss —- Extreme Loss

g. Maintain regular attendance and be punctual:

No — Mild Loss —- Moderate Loss —- Marked Loss —- Extreme Loss

h. Sustain an ordinary routine without special supervision:

No — Mild Loss —- Moderate Loss —- Marked Loss —- Extreme Loss

i. Deal with stress of semi-skilled and skilled work:

No — Mild Loss —- Moderate Loss —- Marked Loss —- Extreme Loss

j. Work in coordination with or proximity to others without being unduly distracted:

No — Mild Loss —- Moderate Loss —- Marked Loss —- Extreme Loss

k. Make simple work-related decisions:

No — Mild Loss —- Moderate Loss —- Marked Loss —- Extreme Loss

l. Complete a normal workday or workweek without interruptions from psychologically based symptoms:

No — Mild Loss —- Moderate Loss —- Marked Loss —- Extreme Loss

m. Perform at a consistent pace without an unreasonable number and length of rest periods:

No — Mild Loss —- Moderate Loss —- Marked Loss —- Extreme Loss

11. Is ability to respond appropriately to supervision, coworkers and work pressure in a work-setting affected by the impairment? If “no”, go to next question. If “yes”, please check the appropriate block to describe the individual’s ability to perform the following work-related mental activities.

Yes ______ No______

For each item listed below indicate one of the following:

a. Interact appropriately with the public:

No — Mild Loss —- Moderate Loss —- Marked Loss —- Extreme Loss

b. Ask simple questions or request assistance:

No — Mild Loss —- Moderate Loss —- Marked Loss —- Extreme Loss

c. Accept instructions and respond appropriately to criticism from supervisors:

No — Mild Loss —- Moderate Loss —- Marked Loss —- Extreme Loss

d. Get along with coworkers and peers without unduly distracting them or exhibiting behavioral extremes:

No — Mild Loss —- Moderate Loss —- Marked Loss —- Extreme Loss

e. Maintain socially appropriate behavior:

No — Mild Loss —- Moderate Loss —- Marked Loss —- Extreme Loss

f. Adhere to basic standards of neatness and cleanliness:

No — Mild Loss —- Moderate Loss —- Marked Loss —- Extreme Loss

g. Respond appropriately to changes in a routine work setting:

No — Mild Loss —- Moderate Loss —- Marked Loss —- Extreme Loss

h. Be aware of normal hazards and take appropriate precautions:

No — Mild Loss —- Moderate Loss —- Marked Loss —- Extreme Loss

i. Travel in unfamiliar places :

No — Mild Loss —- Moderate Loss —- Marked Loss —- Extreme Loss

j. Use public transportation:

No — Mild Loss —- Moderate Loss —- Marked Loss —- Extreme Loss

k. Set realistic goals or make plans independently of others :

No — Mild Loss —- Moderate Loss —- Marked Loss —- Extreme Loss

12. Indicate to what degree the following functional limitations exist as a result of your patient’s mental impairments.

FUNCTIONAL LIMITATION DEGREE OF LIMITATION

a. Restriction of activities of daily living:

None _ Slight __ Moderate __Marked * __ Extreme __

b. Difficulties in maintaining social functioning:

None __ Slight __ Moderate __ Marked ___ Extreme ___

c. Deficiencies of concentration, persistent or pace resulting in failure to complete tasks in a timely manner (in work settings or elsewhere)

Never __ Seldom __ Often __ Frequent ___ Constant ___

d. Episodes of deterioration or decompensation in work or work-like settings which cause the individual to withdraw from that situation or to experience exacerbation of signs and symptoms (which may include deterioration of adaptive behaviors)

Never ___ Once or Twice ___ Repeated ___ Continual ___

*Note: Marked means more than moderate, but less than extreme. A marked limitation may arise when several activities or functions are impaired or even when only one is impaired, so long as the degree of limitation is such as to seriously interfere with the ability to function independently, appropriately and effectively.

13 . Can your patient manage benefits in his or her own best interest?

Yes _____ No

14. PERIOD OF RESTRICTION: Has the individual’s condition existed and persisted with the restrictions as outlined in this Medical Source Statement at least since (date _______) ?

Yes _____No_____

If not, state the first date the patient’s condition existed and persisted with such restrictions.

15. Does the patient have a history of alcohol or drug use?

 

Dated _____________________________

______________________________
Printed Name

______________________________
Signature Block

 

The bottom line is always this:

If you cannot do the work you did in the past, the Social Security Administration will see if you are able to adjust to other work. The Social Security Administration considers your medical and mental conditions and your age, education, and past work experience and any transferable skills you may have. If you cannot adjust to other work, your claim will be approved. If you can adjust to other work, your claim will be denied.

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