Medical source statement form: what it is, a free copy, and how to get it filled out.

A medical source statement is the form a medical provider completes to describe what you can still do in a workday despite your impairments. Social Security weighs it by how well it is explained and how consistent it is with your records. Below is a free copy of the form I use, built around SSA's own function-by-function categories, and plain instructions for getting it completed.

Get the form.

What the form asks.

• Lifting and carrying, occasional and frequent.
• Standing and walking, total and at one time.
• Sitting, total and at one time.
• Need to change position, elevate legs or use an assistive device.
• Postural activities.
• Manipulative activities.
• Environmental restrictions.
• Time off task.
• Absences per month.
• Onset date.
• For each: a space for the clinical basis and the records that support it.

What makes it count.

Explanation. A ticked box with nothing behind it is the weakest evidence in the file. Every limit needs a reason and a record.

Consistency. The judge compares the form with your treatment notes, your function report, and the consultative examination. Contradictions that are not explained sink it.

The source. For claims filed after March 27, 2017, physicians, psychologists, nurse practitioners, physician assistants and several other licensed providers are acceptable medical sources; the weight depends on the explanation and the record, not the title.

If your doctor won't fill it out.

Ask once more, in writing, and attach the form; some practices refuse verbal requests and accept written ones. Ask whether a physician assistant or nurse practitioner in the practice will complete it. If the answer is still no, an independent clinician can complete it from your complete records. That is what I do. I review the file, tell you free of charge whether it supports a statement, and if it does I complete the form and attach a narrative that cites your records page by page.