What does Medically Determinable Physical or Mental Impairment Mean?

A medically determinable physical or mental impairment is a medical condition that can be shown to exist by medically acceptable clinical and laboratory diagnostic techniques. (20 CFR §404.1508). Social Security Regulations specifically state, “a physical or mental impairment must be established by medical evidence consisting of signs, symptoms, and laboratory findings, not only by your statement of symptoms.”

Even if you have a number of symptoms that are preventing you from working, if you have not received a diagnosis, you cannot be found disabled. (See 20 CFR §404.1529). This is why medical treatment is so important to Social Security disability claims. If your symptoms, such as pain, fatigue, weakness, or nervousness, are not explained with medical signs or laboratory findings that show a medically determinable impairment, Social Security cannot determine that your symptoms affect your ability to do basic work activities. (See 20 CFR §404.1529).

Obtain a Medically Supported Diagnosis Before Applying for Disability Benefits.

If you are experiencing symptoms that prevent you from working, you must receive treatment to determine the cause of your limitations. Once you receive a diagnosis, your symptoms must be supported by signs and laboratory findings. “Signs are anatomical, physiological, or psychological abnormalities which can be observed, apart from your statements.” (20 CFR §404.1528). Laboratory findings are “anatomical, physiological, or psychological phenomena which can be shown by the use of medically acceptable laboratory diagnostic techniques.” (20 CFR §404.1528).

In the simplest form, you must receive treatment, your doctor must confirm that the symptoms you express are occurring, and test results should support the diagnosis. If you have not been diagnosed, or your diagnosis is not supported by signs and laboratory findings, you cannot be found disabled.

I suggest to my clients that they have open conversations with their doctors about their medical condition. If you are unable to obtain a diagnosis from your primary doctor, ask for a referral to a specialist. If you are diagnosed with a condition, but have not underwent any medical testing, ask if a test could confirm your diagnosis. Make sure that your doctors are asking you about your condition on each visit, and that you report any symptoms that you are experiencing.

Persistence is so important when you are suffering from serious symptoms affecting your ability to work. Make sure that your doctor understands what you are experiencing, and that her or she is helping you obtain an explanation and treatment for your symptoms. If your condition cannot be explained by a physical condition, also ask your doctor to explore possible psychological causes.

This article was written by Steven Butler. Steven is a partner at Linarducci & Butler, PA and his practice is limited to Social Security Disability/SSI claims. To schedule a consultation with Steven, please use the Linarducci & Butler Contact Form or call 302-613-0707 to schedule an appointment.

No related posts.

Related posts brought to you by Yet Another Related Posts Plugin.

Episode 6 of Social Security Disability Law Weekly Podcast includes discussion of: importance of local attorneys in Social Security Disability Claims; use of an iPad in Administrative Law Judge Hearings; don’t blame the messenger when unpleasant information is communicated about your disability or SSI claim; Social Security Denials Remain High in Delaware; impact of disability on Social Security Retirement benefits; and concept of medical record lag in Social Security claims. Download Episode 6 or press play below to listen in your browser.

Show Notes: Social Security Disability Law Weekly Podcast Episode 6

• Subscribe in iTunes (subscribe in iTunes)

This Week’s Topics:

• Off Topic
  • Support local attorneys – discussion of advantages of having a local attorney
  • Is my attorney using an iPad?
• Issues during my week in practice
  • Don’t Blame the Messenger!
    • Finding out that you don’t qualify for Social Security disability can be difficult, but it is important to remember that the person communicating the message to you isn’t the one making the rules.
• Social Security News (Discussion of Topics Reported in the News and Blogs this Week)
  • Social Security Denials Remain High by Mike Chalmers of the Delaware News Journal
    • Further discussion of the relatively high denial rate for Social Security disability claims by Delaware Administrative Law Judges
  • Social Security Disability Benefits at Retirement Age by Scott Lewis of Indiana Social Security Disability Lawyer Blog
    • Description of what happens when you reach retirement age and are on disability
    • Reminder to consider loss of benefit when on Early Retirement instead of disability
  • The Medical Records Time Lag by Gordon Gates of the Social Security Disability Lawyer Blog
    • More complete medical records can help you win your claim

Closing Credits:

• Contact Steve Butler to Discuss Social Security Disability Law Weekly
  • DelawareDisability.com Contact Form
  • Email: Steve@SSAlaw.us
  • Twitter: @DisabilityGuy
  • Facebook: http://facebook.com/SSALaw

I hope you enjoyed the sixth episode. Please feel free to give me any feedback for improving future episodes. If you enjoy the podcast, you can subscribe in iTunes.

Social Security Disability Law Weekly is a podcast devoted to issues in Social Security Disability Law. Discussion is focused on Social Security Disability Insurance and Supplemental Security Income payments. Social Security Disability Law Weekly is hosted by Steven Butler of Linarducci & Butler, PA.

No related posts.

Related posts brought to you by Yet Another Related Posts Plugin.

Social Security Disability Law Weekly is a podcast devoted to issues in Social Security Disability Law. Discussion is focused on Social Security Disability Insurance and Supplemental Security Income payments. Social Security Disability Law Weekly is hosted by Steven Butler of Linarducci & Butler, PA.

Episode 4 includes discussion of: emergency room treatment in disability claims; Delaware District Court Appeals; Delaware State Bar Association Seminar on Social Security; Disability Onset Date when filing a second application for benefits; Attorneys at Administrative Law Judge Hearings; and high Global Assessment of Functioning (GAF) scores. Download Episode 4, or press play below.

Show Notes: Social Security Disability Law Weekly Podcast Episode 4

-          Subscribe in iTunes (subscribe in iTunes)

This Week’s Topics:

-          Issues during my week in practice

• Emergency Room Treatment as Primary Care
  • Discussion of using hospital as only source of treatment
  • Suggestion to consider low-cost medical clinics as alternative (Delaware Low-Cost Healthcare)
• Meeting to discuss Social Security Appeals with Chief Judge Gregory Sleet of the United State District Court for the District of Delaware
  • Chief Judge Sleet brought together Delaware Attorneys that practice in the Social Security area with representatives from the Social Security Administration General Counsel’s office to discuss Social Security Issues at the District Court level
• Delaware State Bar Association Social Security Disability Ethics Presentation
  • Discussion about Delaware State Bar Association CLE on “Can Social Security Disability Help Your Client?” (Registration Form)

-          Social Security News (Discussion of Topics Reported in the News and Blogs this Week)

• Disability Onset in Subsequent Claims by Aaron Rifkind of Illinois Social Security Blog
  • Social Security allows individuals to file a new claim for disability benefits after being denied by an Administrative Law Judge, but you can only be found disabled beginning the day after the ALJ denial
  • What date should you use as your alleged onset date if you file a new claim
• Am I Required to Have an Attorney at a Hearing by Tim Moore of Disability Secrets Blog
  • Discussion of factors that should be considered when determining if you should be represented at an ALJ hearing
• Is GAF of 65 Too High? By Gordon Gates of the Social Security Disability Lawyer Blog
  • Global Assessment of Functioning or GAF scores are a tool used by Mental Health Providers (psychiatrist, psychologist and therapists) to provide a snapshot of your functioning at the time you are evaluated
  • GAF scores of 51 or higher, normally cause problems in being approved for Social Security Disability based on mental illness
  • Disability cannot be determined solely based on a GAF score

Closing Credits:

-          Contact Steve Butler to Discuss Social Security Disability Law Weekly

• DelawareDisability.com Contact Form
• Email: Steve@SSAlaw.us
• Twitter: @DisabilityGuy
• Facebook: http://facebook.com/SSALaw

I hope you enjoyed the fourth episode. Please feel free to give me any feedback for improving future episodes. If you enjoy the podcast, you can subscribe in iTunes.

No related posts.

Related posts brought to you by Yet Another Related Posts Plugin.

This is the premiere episode of my new podcast focusing on Social Security Disability issues. I plan on posting new episodes on a weekly basis. The purpose of this podcast is to allow me to talk in more detail about issues in Social Security Disability Insurance and Supplemental Security Income claims. This episode focuses on: introducing myself to my listeners; discussing contradiction between unemployment and Social Security Disability; discussion of privacy concerns when filing a District Court disability appeal; importance of treating physician opinion in Social Security Disability claims; why Social Security uses Consultative Examinations; and importance of being able to perform 40 hours of work per week on a sustained basis in order to be found not disabled.

Show Notes:

Show Intro

• About Me (DelawareDisability.com Profile)
  • Limit Practice to Social Security
  • Write about Social Security on Delaware Social Security Disability Law Blog
  • Represent individuals in Delaware Maryland, New Jersey Pennsylvania
  • Licensed in PA and DE, but can practice administrative Social Security Disability Law in any State
• What I hope to do with podcast
  • Talk in more detail about Social Security Law
  • Review News about Social Security
  • Answer Questions

This Week’s Topics

-  Issues during my week in practice

• Unemployment
  • Explain that unemployment and Social Security Disability can be contradictory
  • Discuss criteria that must be met to qualify for unemployment in Delaware
  • Delaware Unemployment Handbook
• District Court
  • Potential privacy issues when filing a District Court Complaint

-  Social Security News (Discussion of Topics Reported in the News and Blogs this week)

• Treating Physician Opinions
  • Bob Kraft: What is a Medical Source Opinion in a Social Security Disability Claim
  • Gordon Gates: Get Your Doctor’s Opinion Regarding Your Functional Limitations
• Consultative Exams
  • Jonathon Ginsberg: Consultative Exam (CE), Part 1, Part 2, and Part 3
• 40 hours a week
  • Charles Hall: Gotta Be Able to do it 40 Hours a Week
  • POMS DI 24510.057: Sustainability and the Residual Functional Capacity (RFC) Assessment
  • After the podcast Gordon Gates also wrote about this topic: Sustainability and RFC Assessment (Great Read)

-  Closing Credits

• Contacting me
  • DelawareDisability.com Contact Form
  • Email: Steve@SSAlaw.us
  • Twitter: @DisabilityGuy

I hope you enjoy the first episode, and please feel free to give me any feedback for improving future episodes. Simply press the play button below to listen in browser, or click the download link to download. (You can also subscribe in iTunes.)

No related posts.

Related posts brought to you by Yet Another Related Posts Plugin.

Closing of Your Administrative Hearing Record

Normally you will not receive your decision at your hearing. The ALJ usually explains that a decision will be made and mailed to you shortly after your hearing. If all the evidence has been submitted and no further medical development is necessary, the ALJ will close your administrative record.

As previously discussed in how to prepare for an ALJ Hearing, it is extremely important to submit all of your medical records before your hearing is held. Ideally, the ALJ should always close your record at the conclusion of the hearing. If the record is not closed, further delay in issuing a decision will occur. The following are examples of situations of when the ALJ may determine that your record cannot be closed immediately:

• The ALJ determines that information available from your treating sources does not fully explain your limitations. In this situation, the ALJ may need to schedule you for a consultative examination (CE) at the expense of the Social Security Administration to determine your capabilities. This should only be required in situations where your limitations cannot be determined from the information provided by your treating medical sources.

• The ALJ needs additional information from future medical visits to determine the current status of your medical condition. For example, you have completed chemotherapy and radiation for cancer, but you have not yet seen your oncologist or had follow-up testing to determine if the therapies were successful. In this situation, the ALJ may require documentation from a future medical visit to determine your eligibility.

• You are not receiving treatment for a medical condition. A medical condition is discussed in your medical records or your testimony, but you have not had active treatment for your condition from a medical source. The ALJ has a duty to develop the record and determine the extent of your limitations. If you are not actively receiving treatment for a documented medical condition, the ALJ may need to schedule a consultative examination to determine if the condition has an impact on your ability to perform full-time work.

• Despite your best efforts, your treating physicians have not provided all medical records. You sent out requests for medical records to all your treating sources as soon as your hearing was scheduled, but you have not received responses from all your doctors. You have advised the ALJ of the difficulty in obtaining records, but still think that it is likely that the records will be received in the near future. If the ALJ believes that you will have the ability to obtain the records, and that you made your best efforts to obtain the documentation prior to the hearing, the ALJ may grant you additional time to provide the missing documentation.

• The ALJ discovers an issue that was not identified prior to a hearing that must be resolved prior to issuing a decision. This may be a nonmedical issue that requires further documentation. For example, recent work is identified, and the ALJ needs to determine if this work would disqualify you from receiving continuing disability benefits. The ALJ can ask that additional documentation be provided before your record is closed and a decision is issued.

This is not an exhaustive list of all the possible reasons that a hearing record can be left open, just the most common ones that I have experienced. However, it is always in your best interest to have all of these issues resolved prior to the hearing if possible.

It is likely that the ALJ has spent a substantial time reviewing your file prior to the hearing, and it is usually in your best interest for the ALJ to make a decision as quickly as possible after the hearing closes. If additional evidence needs to be submitted, it is possible that you will not receive the full attention of the ALJ when your file is reviewed at a later time and it will take longer to receive a decision.

Bench Decision

There are rare occasions where the ALJ is able to issue a decision the day of the hearing. These are referred to as bench decisions. The ALJ determines during the hearing that your condition entitles you to benefits and issues an oral decision. The ALJ in these situations can read your decision into the record, and a detailed decision is never issued. Normally within 7 to 10 days after receiving a bench decision, you receive a 2 to 3 page summary from the hearing office indicating that a fully-favorable decision was issued on the day of your hearing and you were approved for benefits.

Why was I scheduled for a supplemental hearing?

If an ALJ discovers a new issue after your initial hearing is held, it is possible that a supplemental hearing can be scheduled. These normally are only held if consultative examinations reveal new facts, or the ALJ discovers that an important issue was not resolved at the original hearing. In my experience, supplemental hearings are only required about 2% of the time.

Although supplemental hearings mean that you will experience an additional delay in receiving your decision (since your record cannot be closed until after the supplemental hearing), it also allows you a chance to provide additional testimony and submit new medical documentation. The only thing that is certain when a supplemental hearing is scheduled is that a decision cannot currently be issued.

There are four possible hearing outcomes.

• Fully Favorable Decision: A fully favorable decision is issued when the ALJ has approved you for the entire period of disability that you have requested. This normally means that you have been approved based on the date you last worked, and that you will receive continuing monthly benefits. However, you can also receive a fully favorable decision if you agree to amend your onset date, or you request benefits for only a period of time that you agree that you were unable to perform work. This type of decision is usually 6 to 10 pages long, and provides an explanation of why the ALJ decided that you are entitled to Social Security Disability/SSI benefits.

• Partially Favorable Decision: The ALJ agrees that you are entitled to disability benefits, but does not grant you benefits for the entire period that you requested. A partially favorable decision can mean that the ALJ determined that you became disabled at a later date, or that you were disabled in the past but regained the ability to perform work. A partially favorable decision is the hardest decision to write and usually is the longest type of decision issued. Partially favorable decisions average between 12 to 20 pages. The ALJ must provide the rationale for why you were disabled for the period of time that you are found to be entitled to benefits, and also provide the rationale for why you were not disabled during the period that you were denied benefits.

• Unfavorable Decision: The ALJ determines that you are not entitled to benefits for any of the period that you requested. This decision normally ranges from 10 to 16 pages. The ALJ will provide the full details of why you do not meet the requirements of the Social Security Disability programs. Any medical opinions provided by your treating physicians should be discussed in an unfavorable decision. The ALJ is required to explain why your doctor’s opinion was not accepted, and why your allegations were not credible.

• Dismissal: The ALJ determines that a medical determination of your disability is not necessary. You are not entitled to benefits, and the only written discussion is why the dismissal is appropriate. Normally dismissals are only issued if you fail to attend your scheduled hearing, you filed a late request for a hearing and the ALJ determines that you did not have good cause, or you voluntarily withdrew your request for a hearing.

How long does it take to receive an ALJ Decision?

In Delaware, most ALJ decisions are issued 30-90 days after the administrative record is closed. However the ALJ has as long as they need to issue a decision. The longest that I have had to wait for a client’s decisions is 13 months. Decisions are normally mailed to you and your attorney on the same day, and the attorney is never supposed to be advised of what the decision is until they receive it in the mail.

• Bench decisions and dismissals are the easiest decisions to issue, so they are normally issued within about a week of the hearing.

• Fully favorable decisions are normally issued within 30-45 days of the record being closed. These are the easiest of the written decisions to issue. Since the ALJ is likely accepting your doctors medical opinion and finding you fully-credible, not as much documentation is necessary.

• Partially favorable and unfavorable decisions are the hardest decisions to write. The ALJ is required to provide detailed discussion of why your treating physician’s medical opinions are being disregarded, and why you are not believable. Since it is likely that these decisions will be appealed, the ALJ must make sure that they have followed all the Social Security Administration rules and regulations so that it is unlikely that their decision will be reversed.

Why does it take so long for the decision?

Decisions are not easy to write. Even though about 75% of the decision includes form language, the remaining 25% is focused on the information in your administrative file. The average written part of the administrative file for my cases is about 350 pages. All of the written documentation and hearing testimony must be summarized in the decision.

Even if you are approved for benefits, the ALJ must explain why your documentation supports that conclusion. Each ALJ is expected to decide about 400-600 cases per year. ALJs usually review your file prior to a hearing, hold a hearing and listen to testimony, decide whether you will be approved for benefits, and then issue the written decision. If your case involves unusual factors, legal research may also be required.

Although ALJs have staff that assist in preparing the case file and issuing your decision, it is still a time consuming process. I normally spend a minimum of 8-10 hours preparing every case before an ALJ hearing. In order to issue the recommended number of decisions per year, an ALJ can only spend about  a day on each claimant. If the ALJ has a full hearing schedule, it does not leave a lot of time to actually issue decisions.

What should I do if I experience a delay in receiving my decision?

The most important advice I can give a client while waiting for a decision, is to be patient. If you are represented by an attorney, you should never communicate directly with the hearing office. The last thing that you want to do is annoy the person that is making a decision on your claim. ALJs are usually very close to their staff, and if the staff complains about you, it is less likely you will be happy with your decision.

I normally do not do anything until after a client has been waiting for 60 or more days for a decision. I receive a monthly report of all my pending cases from my local Office of Disability Adjudication and Review so I am able to determine if any case has been closed and I have not received a decision. If no decision is made in 60 days, I politely ask the ALJ’s assistant if there is any specific issue causing a delay in the decision being issued (for example, the record is not closed). If I discover an issue, I offer assistance in resolving it.

If a decision is still not received within 90 days, and there are no outstanding issues, I send a courtesy letter to the ALJ. I usually make a short argument reminding the ALJ of why I believe my client should be approved, and politely ask if I can provide any additional information to help with the decision process.

I normally warn my clients that it is likely that are going to be denied benefits if they experience a delay of more than 90 days in receiving their decision. Although I hate to annoy ALJs, I usually do become more pushy after 90 days have passed. I will discuss options with my clients and take any additional steps that are required to help obtain a timely decision.

Conclusion

The important thing to remember after the hearing is that hardest part has been completed. You have done everything that you can to establish the severity of your condition, and you have obtained the necessary medical documentation. All you can do after the hearing is wait for the ALJ to take the information that has been provided, process it, and issue a decision.

This article was written by Steven Butler. Steven is a partner at Linarducci & Butler, PA and his practice is limited to Social Security Disability/SSI claims. Steven offers free initial consultations for Social Security Disability/SSI claims to residents of Delaware, Maryland, New Jersey and Pennsylvania. To schedule a consultation with Steven, please use the Linarducci & Butler Contact Form or call 302-613-0707 to schedule an appointment.

No related posts.

Related posts brought to you by Yet Another Related Posts Plugin.

When reviewing disability, the Social Security Administration requires medical proof of your disability. This means that the Social Security Administration will look for objective results that support your limitations. It is important that your treatment records contain details reflecting your symptoms, your response to treatment, results of diagnostic testing, and a plan of treatment.

The Medical Society of Delaware (“MSD”) is a society of physicians with the core purpose to “guide, serve and support Delaware physicians, promoting the practice and professional medicine to enhance the health of our communities”. In May 2006, MSD developed treatment guidelines for chronic pain. Although MSD abandoned the development of new guidelines in February 2009, the previously developed guidelines remain available for review.

According to MSD, the guidelines were created to assist primary care physicians in treatment of patients with chronic pain in recognition that chronic pain causes physical and emotional suffering of patients. It is specifically recommended by MSD that consultation with specialists be incorporated into the patient’s treatment plan. Physicians are directed to consider not only the pain diagnosis, but also emotional and functional impact pain has on their patients.

The following areas are notable in the guidelines:

• The diagnosis of a painful condition should include an extensive differential diagnosis that rules out treatable and reversible etiologies while rationally managing symptoms of severe pain.
• An initial assessment of chronic pain should include a detailed history (including vocational issues related to pain), full physical exam, consideration of diagnostic studies, differential diagnosis, and a plan of care. The plan of care should be developed with consideration of patient’s history, examination, and goals.
• When implementing a treatment plan, physicians are instructed to ask about pain regularly, accept patient reports of pain, intervene early, and provide information that helps empower patients to make appropriate decisions.
• Timetables should be developed and the rationale of treatment should be discussed with patients. Documenting the treatment by measuring the progress of pain is essential.
• Objective examination results that reveal abnormalities should raise red flags that lead to specialist referral.
• After diagnostic assessment of pain, conventional treatment (including physical therapy, exercise, chiropractic evaluation and short acting pain medications) should be followed by specialist referral if no improvement in symptoms after more than 6 weeks of treatment.
• Family physicians should determine if psychiatric symptoms exist and consider referral for psychiatric or psychological assessment.
• After an initial treatment plan is created, physicians should monitor and record changes in medical history, perform a focused exam to correlate subjective complaints, observe functional limitations, order and review diagnostic testing, and revise the treatment plan based on the patient’s response to treatment.

The guidelines suggested by MSD explain why specialist care is important when you suffer from long-term chronic pain. If your family physician has not referred you for specialist care, it is important that you discuss and question that decision. If your pain fails to respond to the treatment that you are receiving, suggest additional care to better evaluate your symptoms and discuss the guidelines with your physician.

I am not suggesting that a family physician should not be involved in chronic pain treatment, only that your physician should realize when additional care is needed. The plan for pain management care should be reviewed with your family physician, and your family physician should manage and coordinate your care with other physicians. The purpose of these guidelines is to help you obtain relief of your pain. If your physician follows these guidelines, your condition will be better documented, you will receive heightened care for your condition, and it will ultimately be more likely that you will qualify for Social Security disability benefits if your condition fails to improve.

This article was written by Steven Butler. Steven is a partner at Linarducci & Butler, PA and his practice is limited to Social Security Disability/SSI claims. Steven offers free initial consultations for Social Security Disability/SSI claims to residents of Delaware, Maryland, New Jersey and Pennsylvania. To schedule a consultation with Steven, please use the Linarducci & Butler Contact Form or call 302-613-0707 to schedule an appointment.

No related posts.

Related posts brought to you by Yet Another Related Posts Plugin.

Sample Social Security Disability Denial Letter

My clients are often concerned that they were denied benefits because their doctors indicated to Social Security that they could work. The notice specifically states, “the following reports and records were used to decide your claim”. It is often assumed that if a doctor is listed in the notice, that a medical report was provided regarding the individual’s disability status. This assumption is normally wrong. In my experience, 99% of the time only medical records were provided to the Social Security Administration after the Disability Determination Service requested information. The notice is simply providing a list of any doctors that provided medical information to the Disability Determination Service.

What Information did my Doctor Provide to Social Security?

Often your physician does not even realize that he or she has sent information to the Social Security Administration. This is because your doctor’s staff normally responded to the medical request on your doctor’s behalf. In Delaware, the Disability Determination Service is only authorized to provide a flat fee of $15 for any medical evidence requested from your doctor. Most doctors are not willing to provide a detailed medical opinion regarding your disability and to make copies of all of your medical records for $15. Consequently, they simply provide a copy of your medical records.

The reason that it is important to understand that Social Security simply relied on medical records, is because otherwise you may assume your doctor believes that you can work and that you are not disabled. I have had multiple clients that have told me that they did not appeal a decision because they believed that their doctor indicated to Social Security that they could work. They never discussed the decision with the doctor, and sometimes even switched to a new doctor because they blamed the denial on their doctor’s report.

But if Social Security Denied me, doesn’t that mean that my Medical Records don�t Support Disability?

If you are pursuing disability benefits, it is important that you discuss your disability application with your doctor. Tell your doctor that you plan to apply for benefits, and ask for him or her to provide you with a letter in support of your disability application. If your physician provides detailed information indicating the limitations that you experience because of your medical condition, it is more likely that the Social Security Administration will actually know your doctor’s medical opinion.

It is not sufficient for your doctor to indicate that he or she believes that you are disabled; he or she also needs to provide an explanation to support that conclusion. Ask your doctor to provide a detailed description of your medical diagnosis, any test results that support your diagnosis, your symptoms and limitations, and how your medical condition would interfere with your ability to complete a normal workday or workweek. The Social Security Administration normally rejects a simple conclusion that you are unable to perform work. Social Security needs to know why your doctor believes that you cannot perform work. Without this detailed information, the Disability Determination Service must try to determine what your doctor thinks based on his or her records alone.

After you receive a denial from the Social Security Administration, I recommend again discussing your disability with your doctor. Ask your doctor to read your decision and determine if your doctor agrees with the decision. If your doctor disagrees with the determination, ask your doctor to provide another letter explaining why he or she disagrees with the conclusion. Ask your doctor if additional treatment is available or if you should be referred to a specialist. Make sure your doctor understands the importance of you receiving disability benefits.

Work with an Attorney to Review and Appeal your Denial.

It is important to remember that the notices sent by the Social Security Administration are form letters. You will not receive a detailed explanation of why your records do not support your disability, instead you will receive only a short summary indicating that your condition will not last long enough in order for you to qualify for Social Security Disability, that you can still perform some type of work, or that you do not meet other non-medical requirements of the disability program. Because this information can be misleading, it is important that you simply do not abandon your claim and accept the conclusion of the Social Security Administration without understanding the decision.

The majority of attorneys that handle Social Security disability claims will see you on a free consultation basis, and usually are willing to review your decision and try to make a determination if additional information can be provided to the Social Security Administration that will establish that you meet the disability eligibility requirements. Take advantage of this free consultation before deciding to abandon your claim, and find out how an attorney can help improve your claim.

This article was written by Steven Butler. Steven is a partner at Linarducci & Butler, PA and his practice is limited to Social Security Disability/SSI claims. Steven offers free initial consultations for Social Security Disability/SSI claims to residents of Delaware, Maryland, New Jersey and Pennsylvania. To schedule a consultation with Steven, please use the Linarducci & Butler Contact Form or call 302-613-0707 to schedule an appointment.

No related posts.

Related posts brought to you by Yet Another Related Posts Plugin.

The following fee schedule has been established by the new Administrative Regulation (24 DE Admin. Code 1700, Sec. 30):

30.1 A patient requesting of a copy of his or her own medical records to be transferred to another physician or to be obtained on their own behalf may be charged a reasonable fee not to exceed the fees set forth in the schedule below, excluding the actual cost of postage or shipping if the records are mailed:

• $2.00 per page for pages 1-10
  
• $1.00 per page for pages 11-20
  
• $0.90 per page for pages 21-60
  
• $0.50 per page for pages 61 and above
  

30.2 The fees set forth in section 30.1 above shall apply whether the records are produced in paper or electronic format.

30.3 The full cost of reproduction may be charged for copies of records not susceptible to photostatic reproduction, such as radiology films, models, photographs or fetal monitoring strips.

30.4 Payment of all costs may be required in advance of release of the records except for records requested to make or complete an application for a disability benefits program.

What is important to note about this regulation is that the fee schedule only applies when a patient requests a copy of his or her own medical records. If an attorney requests records on your behalf, doctors are permitted to charge a higher rate.

This fee schedule is still not ideal for individuals that are applying for Social Security Disability Insurance or Supplemental Security Income payments. For example, under the new fee schedule, doctors are permitted to charge the following rates based on the number of pages of records:

These fees can still result in substantial costs in just obtaining medical documentation that is required to pursue your claim. There is no maximum fee that your doctor can charge you for your records, as long as he or she adheres to the fee schedule. For comparison, Pennsylvania has a flat fee charge for production of records to support any claim under Social Security. The Pennsylvania flat rate in 2009 is $25.09. If your doctor has more than 15 pages of records in Delaware, you would exceed the Pennsylvania flat rate.

The most helpful part of the new regulation is that doctors are not permitted to require prepayment for records to be used for completing a disability application. This means that if you notify your doctor that you need records to pursue Social Security Disability, they are required to provide the records even if you cannot immediately pay the costs. (You would still be responsible for repaying the costs, your doctor is simply required to release the records prior to receiving payment.)

Although the new regulation is a good start, it is important that you still express your concern about medical record costs to your State Representative, State Senator, and the Board of Medical Practice. If your physician refuses to adhere to this fee structure, and you are Delaware Resident, it would also be important to notify the Board of Medical Practice of your physician’s failure to comply with the regulations.

Relevant Links:

• Board of Medical Practice
  
• Locate your State Senator
  
• Locate your State Representative
  

This article was written by Steven Butler. Steven is a partner at Linarducci & Butler, PA and his practice is limited to Social Security Disability/SSI claims. Steven offers free initial consultations for Social Security Disability/SSI claims to residents of Delaware, Maryland, New Jersey and Pennsylvania. To schedule a consultation with Steven, please use the Linarducci & Butler Contact Form or call 302-613-0707 to schedule an appointment.

No related posts.

Related posts brought to you by Yet Another Related Posts Plugin.

Electronic medical records are important because they allow essential information to be communicated in a legible fashion. During an Administrative Law Judge Hearing earlier this week, I had a Judge remark to my client that his mental healthcare provider “needs to learn to write”. Because of the poor quality of these medical records, my client had been denied benefits multiple times. It was impossible for other medical professionals to review these records and understand the degree of my client’s impairment.

Why you should want Electronic Medical Records

• Legibility – records that are typed are easy to read. If your records are not legible, it is impossible to determine the treatment you have received, the complaints that you have experienced, and the objective physical examination results that support your disability. Beyond Social Security, legible records are important if you switch healthcare providers, or if you require emergency care. It would be easy for a wrong diagnosis to be made or to be provided a medication that you have had a bad reaction to if a new physician cannot understand your previous records.
• Redundancy – electronic medical records should be backed-up. Any physician that stores your records electronically should also have a system to archive your records offsite. This is important because if the originals are destroyed, your physician should be able to restore them. If original paper documents are destroyed, the are likely gone forever.
• Access – it should be easier and cheaper to obtain electronic records. Traditional records had to be copied by an individual. Normally the records were bound in a folder and commonly they were hard to feed through a copier. Copying traditional medical records was a time consuming effort. Electronic medical records can usually be printed out with a few clicks of the mouse. Some systems even allow electronic transmission to other doctors, insurance companies, hospitals, and government agencies. This saves your healthcare providers time and should also minimize the cost of record production.
• Quicker Social Security Decisions – if your records are easier to obtain and read, the Social Security Administration is able to issue decisions quicker. In pilot projects where Social Security has been able to obtain medical records electronically, claims have been processed almost 50% quicker (Commissioner Michael Astrue Testimony Before Congress, November 19, 2009). Even your records are not transmitted electronically, your file can be reviewed quicker when the information is provided legibly.

Problems with Electronic Medical Records

I agree that there are currently major problems with the way that electronic medical records are used. It appears that systems that are used and sold to the majority of physicians were not designed with the practice of medicine in mind.

The number one problem that I encounter with electronic medical records is every visit is treated as a full physical examination. Even routine visits for blood pressure checks, common colds, test result reviews, or medication checks, still result in 4 to 8 pages of medical records. Electronic medical records commonly include sections for your complaint, your history, review of your systems, objective examination findings, your diagnosis and your doctor’s plan of care. All of these fields are included on each visit regardless of whether each section was updated (normally only the complaint section and the plan of care is updated).

This method of recording information results in unreliable information. I routinely find that my client’s medical conditions are not described in the review of systems or examination sections when they see a doctor for a routine visit. I have had several clients with spinal fusions where the electronic medical records indicated that a physical examination revealed full range of motion and normal musculoskeletal findings. In the history section, I have seen records that indicated on each of 18 visits over a 2 year period, that my client had started to have leg pain the previous week. Clients have been denied Social Security disability benefits because their treating physician indicated that there were no complaints in areas where an exam was not actually performed.

Improvements Needed for Electronic Medical Records

What is necessary in order to improve electronic medical records, is to only record details that are actually obtained during the visit. The complaint section and the plan should be updated with new information on each visit, the history section and diagnosis sections should be updated, and the review of systems and objective examination information should only be entered if the information was actually obtained during the visit. If an individual’s history or diagnosis changes, the change should be noted with the date of the change and with emphasis added to the new details so that the change is easy to identify. Review of systems and objective examination details should only be included when those details are obtained from a patient, and only the details obtained on that visit should be included.

These changes would help reduce the number of pages of medical records and make the information more reliable. Cutting and pasting should be frowned upon, and prompts should be provided to ask a healthcare provider if the items were reviewed or if exams were completed before the information is inserted into the record. A physician should not be willing for sections to be included in a medical record if the information was not actually obtained on that visit.

What you Should Do

The problems with electronic medical records are important to you because you can be denied disability benefits because of poor documentation. If your physicians do not accurately record your subjective complaints, or indicate that examinations are performed that have not actually occurred, you need to consider switching physicians.

The Social Security Administration requires objective evidence to support your disability, and can deny you if the objective evidence reveals that there is no impairment. Even if one specialist properly documents your condition, if another physician’s records indicate a normal exam, a conflict about the severity of your condition has been created. The Social Security Administration will be required to resolve the conflict and find that one physician is reliable and that the other is not.

I encourage all my clients to be proactive about their treatment. It is important that you know if your physicians are correctly documenting your condition. Ask to review your medical records, and if you cannot read them, it is unlikely anyone else can. If your complaints are not included in your records, it is important to realize that Social Security will be unable to consider them. If there are indications that exams were performed that were not, or normal findings or no complaints are recorded in areas that you experience problems with, it is important to obtain clarification or explanation from your healthcare provider about the conflict. If your condition is not documented well by your treating physician, it is more likely that Social Security will determine that your impairment is not severe, and that your Social Security Disability Claim will be denied.

This article was written by Steven Butler. Steven is a partner at Linarducci & Butler, PA and his practice is limited to Social Security Disability/SSI claims. Steven offers free initial consultations for Social Security Disability/SSI claims to residents of Delaware, Maryland, New Jersey and Pennsylvania. To schedule a consultation with Steven, please use the Linarducci & Butler Contact Form or call 302-613-0707 to schedule an appointment.

No related posts.

Related posts brought to you by Yet Another Related Posts Plugin.

The ALJ denial rates have serious implications on individuals that live in Delaware and have physical or mental disabilities. Because of the high denial rate, more Delawareans are approved at the initial application level than any other point in the Social Security Disability Process.

The Importance of Obtaining Legal Assistance Early

Since more Delawareans are approved at the initial application level, it is important to have help with your Social Security Disability claim as early as possible. The most significant change that I made in my practice since the Dover ODAR office opened in 2004, was actively representing more people at the initial application level. I discovered that clients denied by Dover ALJs could have been approved at the initial application level if additional medical evidence had been provided. When I started representing claimants in 2003, less than 10% of my clients were at the initial application level. Now more than a third of my cases are at the initial application level.

The initial application is important because you have a clean slate. No medical opinions have been provided that indicate that you can work, and you still have an opportunity to submit evidence that can be considered by the Disability Determination Service. If the State Agency Physician is able to review your treating physician’s medical opinion before providing his or her own opinion, it is more likely that your doctor’s opinion will be incorporated into the decision. Because of the importance of being approved early, I focus on building the strongest claim possible before my clients even apply for benefits. If you are approved benefits on your initial application, you never have to worry about the high denial rates of the Dover ALJs.

More Treatment is Necessary to Establish Disability with Dover ALJs

It is extremely difficult to be approved for benefits at an ALJ hearing in Delaware if you do not have specialist care. Even the Dover ALJs that have higher approval rates are unlikely to approve you for disability if you are only receiving treatment from a family physician. Although your family physician may be willing to treat you for every medical condition, it is important that you receive treatment that will improve your chance of being approved.

If you are suffering from a major disability, the Dover ALJs expect you to see a specialist for your condition. Family physicians are less likely to document symptoms to the same extent as a specialist. Since specialist limit their practice, it is also more likely that they will be aware of recent developments in your condition, and be able to offer treatment alternatives that may help. Having specialist care will make it more likely that you are one of the few that are approved if you eventually have to have a hearing in front of a Dover ALJ.

Your Treating Physicians must be Supportive

If your treating physician believes that you can work, it is unlikely you will be approved for Social Security disability benefits. I normally only accept new clients if a treating physician first documents limitations and explains how the limitations would interfere with your ability to work. If your treating physician is not supportive of your disability, the ALJ will only have the State Agency medical opinions to consider when deciding your claim. Since the State Agency medical opinions were likely the basis of your original denial, the Dover ALJs will cite the same opinions to deny you again.

Even when your treating physicians are helpful, it is still possible to be denied benefits. Several of the individuals featured in the New Journal had opinions from multiple doctors supporting their disability. I even routinely have had clients denied benefits when the opinions of Social Security Consultative Examinations supported their disability.

More Documentation is Necessary

Obtaining supportive medical opinions from your treating physicians is only the starting point in proving disability in Delaware. You must also be able to support your symptoms with objective medical evidence. If you have pain, you must have test results that establish the source of your pain. This is normal throughout the United States, the difference in Delaware is that the ALJs are often looking for you to have the tests repeated throughout the time that you are receiving treatment. It is not enough to have a test performed when you initially became disabled; the ALJs also want to see updated tests that are performed shortly prior to the ALJ hearing.

If you are experiencing pain, but have not had surgery performed, it is rare to be approved benefits by many of the Dover ALJs. Even if you had surgery, the ALJs will look at how invasive the surgery is when making a determination on whether you are disabled. Injections are not significant to most of the ALJs in Delaware, and if you are only taking medication for your condition and have not required more invasive care, it is unusual to be approved.

If you are suffering with a mental based disability, you must have treatment with a psychiatrist and a therapist/psychologist. If you fail to take medication, or abuse illegal drugs or alcohol, you have very little chance of approval (even if your doctor indicates that this is caused by your condition). If you are claiming memory or cognitive impairments, it is also important to have psychological and memory testing to document the severity of your symptoms. In my experience, individuals with purely mental based disabilities are rarely approved in Delaware unless they also have required hospitalizations for their condition.

Higher Costs to Pursue Claims in Delaware

Because of the higher standard of disability that we face in Delaware, I have noticed that the cost of pursuing disability benefits has skyrocketed between 2003 and 2009. The average cost in 2003 was below $150 at the ALJ level; today it is not abnormal to have costs of $400-$600. The reason for the increase is the additional evidence the ALJs are requiring. The ALJs want records from every doctor you have seen since your disability began (even if it is not relevant to your disability), and I often must request opinions from each doctor actively treating you. Since the ALJs do not like fill-in-the-blank forms, narrative opinions (that have cost as much as $1,000) are sometimes needed.

Additional costs are incurred for the additional treatment needed. If you have copays for every visit to your doctor, the additional care will result in more out-of-pocket costs. If you see additional doctors, it is also likely that additional tests and treatment will be suggested.

If you experience a unique condition that has flare-ups, it is important to notify your physician of every flare-up. Even when you have learned to manage your condition during flare-ups, it is important that the flare-ups be documented by your doctor. If your flare-ups are not mentioned in your treatment records, many of the Dover ALJs frequently find that the flare-ups did not occur at the frequency that you identified.

Dover ALJs do not Independently Review Your Disability

ALJs are supposed to independently consider all the medical evidence that is in your file and all testimony that is provided prior to issuing a decision. Before a hearing, it is not abnormal to submit over 100 pages of new medical records, and to provide medical opinions from treating physicians for the first time. Due to the length of time it takes for a hearing to be scheduled, normally the Social Security medical opinions in your file are at least one year old when the hearing is held.

The Chief ALJ of the Social Security Administration, Frank Cristaudo, stressed in the News Journal the importance of ALJs independence. He indicated, We allow the judges to make the decisions they think are appropriate. This stance is commendable, but many of the Dover ALJs fail to exercise their independence.

Although there is so much new information available for the first time at the ALJ hearing, it is common for Dover ALJs to ask, “Why was the Disability Determination Service (DDS) wrong in denying the claim?”. I must be prepared to explain why the State Agency Physician’s medical opinion does not adequately address your limitations (although it is obvious that these doctors never had the opportunity to review your new medical documentation), and I have been reminded by one ALJ that the State Agency Physicians are not biased like treating physicians.

This is a concern because the ALJs are not independently considering your disability. When the majority of Dover ALJs ask for Vocational Expert testimony, they ask the Vocational Experts to only consider limitations that were identified by the State Agency Physician, and when they issue a decision, the State Agency Physician (that never examined you) is normally awarded the most weight. It is rare for the ALJs identified by the News Journal to believe you or your treating physician. Even when they approve benefits, it is usually based on information that was previously provided by the State Agency Physician or a Consultative Examination Physician.

Approved for Less Benefits

The News Journal article briefly provided an example of one individual that was ultimately found disabled, but it was determined that his disability did not begin until 2 years after his employment ended. It is common for decisions from the Dover ALJs to be partially favorable. This means that although you are approved for benefits, the ALJ will find that your disability was not “severe enough” to cause you to become disabled until sometime after you originally stopped working.

ALJs in other areas commonly find that a claimant was disabled when their job ended, even if additional care was not received until a later date. For example, if you are suffering from depression and lose your job because of the condition, but did not start seeing a psychiatrist until after you had to be hospitalized 6 months later, other ALJs will find that your condition was severe enough for you to qualify since your job ended. With many Dover ALJs, you would not be approved until the date that you had to be hospitalized.

If you have a spine impairment, and went through therapy and injections before it was determined that you needed surgery, most ALJs would realize that your doctors wanted to try less invasive treatment before considering surgery. However, with the Dover ALJs discussed in the News Journal, I have had several clients that have not been approved until the date of their surgery. Although these individuals had experienced pain severe enough to prevent them from working for several months (to several years), the ALJs determined that they were not actually disabled until surgery was necessary.

One Dover ALJ is also routinely finding that individuals are only disabled for a brief period. An ALJ normally only awards a closed period of disability if an individual’s condition has actually improved enough to allow them to return to work (or the individual admits that they have the ability to return to work). This specific Dover ALJ routinely issues partially favorable decisions finding that a person was only disabled for a period of 12-18 months. The ALJ will indicate that an individual has improved even if the treating physician does not believe the symptoms resolved.

The News Journal did not provide specific details on the number of fully-favorable versus partially favorable decisions in the article, but I have information for each of the ALJs for fiscal year 2008. The ALJ that was discussed the most by the News Journal had an overall denial rate of 59.2% in 2008, but only issued fully-favorable decisions 22.3% of the time. The remaining 18.5% were partially-favorable decisions. For individuals age 18-49, this same ALJ issued fully-favorable decisions 10.3% of the time, and issued partially favorable decisions 19.9% of the time.

This is alarming because when an onset date is voluntarily amended, or an individual agrees to a closed period of disability, this counts as a fully-favorable decision. This suggests that if individuals did not voluntarily make these changes, the ALJ would have a much higher partially favorable rate (or possibly even deny more claims). Therefore, even some of the people that are approved by the ALJ with the highest denial rate are not actually receiving all the benefits they deserve.

Fewer People Offered Representation

Because the practice of law is a business, it is important that attorneys are able to make a profit when representing individuals. Although I would like to help everyone that contacts me, I must focus my limited resources on helping those people that have the most realistic chance of being approved for benefits. When fewer people are approved for benefits, it becomes harder to offer representation to all the people that need it.

The higher denial rates make it less likely that I can offer representation if your condition is not well documented. When I started practicing in 2003, I would routinely take cases where my client did not have adequate documentation of their disability. I would work with my client to help them establish the necessary medical care, and I would file appeals while they strengthened their case. I realized that the individual may be denied one or more times, but I knew that I could help them improve their future chance of approval.

Now when I meet with a potential client, I am unable to devote my resources to claims that are poorly documented. I have had multiple clients denied benefits that have had 4 or more supportive medical opinions from treating physicians. If it is difficult for someone with the support of all of their doctors to be approved for disability benefits, it is nearly impossible for an individual with little or no medical support to be approved.

The result of this change is that Delawareans that would have been offered representation in the past must now pursue benefits without legal assistance. All of the Delaware attorneys that I speak with that handle Social Security Disability cases are also being more selective in accepting clients. I currently only begin to represent 20% of individuals that request my help. If all of the Delaware attorneys are being more selective in offering representation, the net effect is that fewer claimants are represented.

Claims with Supportive Evidence are Not Being Appealed

If you are denied by an ALJ, you have a right to appeal your decision to the Appeals Council. The Appeals Council typically takes anywhere from 6 months to 2 years to issue a decision. In 2008, Appeals Council denied 73% of claims filed, and only approved 2%. Although Appeals Council remanded 22% of cases, this simply means that your claim will be sent back to the same ALJ that denied you previously. In my experience, the Dover ALJs are no more likely to approve you after your case has been remanded by the Appeals Council.

After being denied by the Appeals Council, you can file an appeal in United States District Court. Unless you can prove that you have very little resources and/or income, it cost $350 to file an appeal to United States District Court. The United State District Court for Delaware issued 30 Social Security Disability decisions in 2008, and remanded 43% for a second hearing (no outright reversals were issued). It took the District Court an average of 527 days to issue a decision in 2008. Between 2004 and 2008, an average of 27 Delaware District Court appeals were filed each year. During the same time, Dover ODAR denied an average of 642 people per year for disability benefits.

The only way that you are assigned a new ALJ for a second hearing is if you can prove bias or your original ALJ is no longer available. I have never had a case assigned to a new ALJ for a second hearing in Dover. If you are successful at getting a second hearing based on an Appeals Council appeal, it is likely that it will take a minimum of 18 months after the ALJ’s original decision before you get a new decision. For cases that are remanded from District Court, it is likely that you will have waited for 3 or more years before you receive another decision.

During the time that you are waiting for the appeals process, you are not receiving benefits. I spend approximately 20 hours preparing a file for the first ALJ hearing. If I have to file an Appeals Council appeal, I spend an average of 10 additional hours working on your claim. District Court appeals take me between 20-25 hours. When a case is remanded for a second hearing, I usually spend at least 10 more hours preparing the case for a second hearing. This does not include the time that my staff spends preparing your file and giving you updates.

When I decide to appeal claims to Appeals Council and United States District Court, I am making a significant investment in my time. If it is not likely that I can obtain a better decision by filing an appeal, I am unable to continue to pursue the claim even if the ALJ technically made errors in your decision. During the entire time that you are waiting for your claim to be decided, I am also not receiving payment for my services. If I spend 40 hours working on an appeal that is not going to be successful, I have spent an entire week of my time that I cannot devote to obtaining additional clients.

Because I am running a business, I have to make a cost-benefit analysis before I agree to take action on your behalf. Since there is only a small chance of receiving benefits after being denied by an ALJ, I appeal only a small number of claims past the ALJ level. I look for ALJ mistakes that are so obvious that I believe that 100% of claims that I appeal to Appeals Council or District Court should be approved.

My main consideration when I decide to appeal is not whether I believe that you are disabled (I believe that 100% of people I represent at hearings are disabled), but whether I believe that you could be approved if you have a second hearing. Based on the small percentage of cases that are filed in Delaware District Court (only about 4% of ALJ denials are appealed to District Court), it appears that other attorneys also take a similar approach. This means that even individuals that have supportive medical evidence and should have been approved benefits are not always appealing their decisions after an ALJ denial.

Conclusion

I am disturbed by what has happened at the Dover ODAR office because it overall is limiting your access to the legal system. Attorneys that were handling large numbers of Social Security Disability Claims in the past are reducing their caseload. Individuals that are unable to work and should be found disabled are being denied benefits. I am reluctant to appeal adverse decisions from the ALJs because it is unlikely that you will be approved for benefits even if your case is remanded. Instead of taking all clients that should be found disabled according to the law, I instead have to focus my attention on taking clients that can be approved based on how the Dover ALJs are applying the law.

I realize that there will always be variances in decision-making, the problem that I had hoped that the News Journal would highlight, is that the variance in Dover is not caused by ALJs exercising their independence, but by some ALJs misapplying the law. I personally have had at least 25 decisions where the ALJ found that my client was not credible because they attended their hearing and responded to questions. (If my client had not attended their hearing, the case would have been dismissed.) I am hoping that the attention that the Dover ODAR office receives from the News Journal articles will at least result in a consistent application of the law so that I can tell my clients that they will receive a fair hearing regardless of the ALJ assigned to their case.

News Journal Articles:

• Disability claims denied more often in Delaware
• After a lifetime of hard labor, body and mind are beaten up
• Woman felt like a ‘beggar trying to get something’
• With a family full of suffering, benefits don’t go a long way
• Hopeless situation sends mom to depths of despair
• Agency refuses to release information about complaints
• Dual roles of judges a source of tension
• Claim denials haunt some to death’s door”
• She fears judge is ‘just waiting for me to die’
• Disability denials troubling to leaders
• Routinely rejecting disability claims deplorable

This article was written by Steven Butler. Steven is a partner at Linarducci & Butler, PA and his practice is limited to Social Security Disability/SSI claims. Steven offers free initial consultations for Social Security Disability/SSI claims to residents of Delaware, Maryland, New Jersey and Pennsylvania. To schedule a consultation with Steven, please use the Linarducci & Butler Contact Form or call 302-613-0707 to schedule an appointment.

No related posts.

Related posts brought to you by Yet Another Related Posts Plugin.