Legal Disclaimer:
The legal advice and citations contained in these templates and outlines were updated for the Washington Medical-Legal Partnership (“MLP”) during the spring of 2014 and are current only as of that date. The MLP intends to update these templates and outlines regularly. In addition, these templates and outlines provide general advice and may not be applicable to your patient’s unique circumstances.
If you have any concerns regarding the currency or applicability of these templates and outlines, please contact Annette Quayle, MLP program coordinator, at .
This disclaimer is for your information and does not need to accompany the letter below.
Social Security Advocacy Letter Examples:
Below are examples of three letters written on behalf of patients by the Medical-Legal Partnership for Children (MLPC) attorney, Scott Crain. Because conditions vary from patient to patient, these letters are intended as informative guidelines rather than a form letter.
When writing a letter, it is generally useful to cite from the Social Security Administration (SSA) bluebook for the specific medical conditions. The Blue Book is available at:
Begin with Part B (for children). If you cannot find the illness or disease in Part B, look to Part A (adults).
Social workers and providers should also include their own first-hand impressions of the patient.
Special Instructions for Patients in Critical Condition:
The SSA will expedite the appeals process if your patient has a critical case. A patient has a critical case if the patient: (a) has a terminal condition; (b) was injured during military service; (c) is homeless; (d) is suicidal or homicidal; or (e) is in dire need. If your patient has a critical case, include the language: “Flag: Critical Case” in bold font in your advocacy letter and clearly note the patient’s special circumstances. For example, if a patient has a dire need, include the language “Flag: Critical Case (DIRE NEED)” at the top of your advocacy letter.
If you believe your patient has a critical case, please consult the SSA provisions, HALLEX I-2-1-40, to ensure that you are aware of the additional steps necessary to properly notify the SSA of your patient’s condition. This provision is available at:
Example 1
Date
Via facsimile and first-class mail
Attorney Adjudicator
Social Security Office of Disability Adjudication and Review
300 5th Ave, Suite 500Seattle, Washington 98104-3389
Facsimile 206-374-7300
Re: Patient Z, claim no. SSN
To whom it may concern:
In response to your request for more information on Patient Z, please find enclosed the following document:
Children’s hospital medical record (Date)
Patient Z was born with spina bifida and hydrocephalus, requiring immediate surgery after his birth. He is dependant on his caregivers for assistance with draining his bladder (up to eight times per day), and has significant motor and developmental delays.
As you can see, Patient Z’s doctor, Dr. W, notes that Patient Z’s developmental delays are now 50 percent greater than his stated age. Per 20 C.F.R. sec. 416.926a(e)(3), Patient Z has an extreme limitation in his day-to-day functioning.
Additionally, the listing for Patient Z’s impairment follows:
111.08 Meningomyelocele (and related disorders). With one of the following, despite prescribed treatment:
A. Motor dysfunction meeting the requirements of 101.02 or 111.06; or
B. Less severe motor dysfunction (but more than slight), and:
1. Urinary or fecal incontinence when inappropriate for age; or
2. IQ of 70 or less; or
C. Four extremity involvement; or
D. Noncompensated hydrocephalus producing interference with mental or motor developmental progression.
Patient Z’s inability to control his head and neck, difficulty moving and manipulating objects with his hands, and his limited ability to use his legs indicates that Patient Z’s meets the listing above as a four-extremity involvement with severe motor delay. Additionally, Patient Z’s urinary problems medically equal the listing above, as he is unable to pass urine on his own. While it may be developmentally appropriate for a child Patient Z’s age to have no control over his bladder, it is medically equivalent to inappropriate incontinence when a child has no ability to evacuate his own bladder and must rely on a caregiver to do so. The resulting difficulty for his caregiver is at least as equal in severity and inconvenience as the listing above.
Thank you for taking the time to review this information, and please do not hesitate to contact me if you have any questions.
Sincerely,
Scott Crain
Attorney
Cc: Parent
Example 2
Date
Social Security Administration
SOCIAL SECURITY
2608 S 47th St
Suite A
Tacoma, WA 98409
Re: Patient S Claim [SSN]
Flag for Dire Need
Request for On the Record (OTR) Decision
Dear Sir or Madam:
I am an attorney representing Patient S, through his grandparents and guardians. Patient S appealed his denial of reconsideration today, and because Patient S clearly meets the listings for 111.08 B(1), I am asking that you process this as an On the Record decision as soon as possible, in addition to Patient S’s dire need for SSI.
Enclosed are the following documents:
Appeal cover sheet
SSA 1699 Appointment of Representative
Seattle Children’s Hospital clinic notes
Children’s SSI Questionnaire
Patient S is sending under separate cover Form SSA827.
I have had an opportunity to meet with Patient S and am writing this letter of observation in support of his claim, as well as to review the enclosed records and request that SSA expedite processing of this claim due to presumptive disability of Patient S and dire need.
Pursuant to listing 111.08, SSA should find that Patient S qualifies for SSI based on his diagnosis of Meningomyelocele (spina bifida) and complications secondary to that diagnosis. These complications include incontinence, such that Patient S is unable to control bladder and bowel movements and must self-catheterize his bladder every three hours. Patient S also has motor dysfunction that is more than slight, as noted by Dr. W in his [DATE] clinic notes. Based on these findings, Patient S meets the listings for 111.08 B(1), which state:
B. Less severe motor dysfunction (but more than slight), and:
1. Urinary or fecal incontinence when inappropriate for age; ….
Dr. W’s notes indicate that, despite prescribed therapy, Patient S is unable to control his bowel and bladder movements. This is clearly inappropriate for his age, as Patient S is nearing adulthood. Additionally, Patient S has reduced sensation and motor impairment in his lower extremities secondary to meningomyelocele. This limits Patient S’s strength in his legs and sensation below his waist. These limitations mean that Patient S is unable to perform many of the day-to-day tasks that might be expected of him. In addition, Patient S has difficulty with pain in his back that is secondary to spina bifida. These symptoms and Patient S’s condition are expected to last Patient S’s entire life.
Patient S’s need for SSI is dire. Without SSI and Medicaid, Patient S will be unable to afford his catheterization equipment and other supplies related to incontinence. This will put him at significant risk for dangerous complications related to incontinence, as noted in Patient S’s clinic notes from Dr. B and Dr. L. SSA should approve this appeal without delay, and ODAR should issue an on-the-record decision based on these findings.
Again, please accept and expedite this application on the basis of dire need. I am happy to provide any additional documentation that you may need to make this decision. Thank you for your attention to this matter.
Sincerely,
Scott Crain
Attorney
cc: Patient S
Encl.
Example 3
Date
Via facsimile only
Attorney Adjudicator
Social Security Office of Disability Adjudication and Review
300 5th Ave, Suite 500Seattle, Washington 98104-3389
Facsimile 206-374-7300
Re:Patient M, claim no. [insert SSN],
Request for On the Record (OTR) Decision
Dear Sir or Madam:
Please consider this request for a decision on the record in the above-entitled matter. Enclosed are the following documents
Seattle Public Schools Special Education Services
Letter from Seattle Public School Assistant General Counsel
Patient M has postpolio syndrome that results in an impairment in her gait and station. Documents related to this impairment have been provided to SSA, and an unfavorable decision on reconsideration was issued. New information from the Seattle Public Schools reveals that Patient M also has a significant intellectual impairment and adaptive functioning limitations that should qualify her for SSI. The delay in obtaining these documents is solely due to the delay in the Seattle Public Schools completing Patient M’s special education evaluation from May 2008, which is documented in these materials.
These evaluation materials show that Patient M has an FSIQ of 61 and some delays in adaptive functioning.
Additionally, the listing for part of Patient M’s impairment follows (112.05 (d)):
112.05 Mental Retardation: Characterized by significantly subaverage general intellectual functioning with deficits in adaptive functioning.
The required level of severity for this disorder is met when the requirements in A, B, C, D, E, or F are satisfied.
…
D. A valid verbal, performance, or full scale IQ of 60 through 70 and a physical or other mental impairment imposing an additional and significant limitation of function;
Patient M’s difficulty in school, as evidenced by her IQ testing and need for specially designed instruction shows a marked impairment in her ability to acquire and use information. Patient M has also been previously determined by SSA to have a marked impairment in moving about and manipulating objects. Coupled with her postpolio syndrome and attendant difficulties with walking, she meets the requirements of the above listing; she is also capable of showing functional equivalence under the SSI rules for children, based on her combination of impairments.
Patient M’s intellectual impairment was only recently diagnosed because the Seattle Public Schools failed to timely complete her evaluation for special education services. Had they timely completed the evaluation in May of 2008, Patient M’s cognitive delay would have been discovered at that time. An email from Seattle Public Schools acknowledging this delay in evaluation is included here for reference.
Thank you for taking the time to review this information, and please do not hesitate to contact me if you have any questions.
Sincerely,
Scott Crain
Attorney
Cc: