Medical Provider Organizer for Your Disability Claim
This worksheet lists every doctor, clinic, therapist, hospital stay, and test connected to your claim, with approximate dates. Social Security builds a disability decision from medical records, so a complete list of who holds them is the most useful page you can bring to an application or appeal.
Print it blank or type into it on screen. Nothing you enter leaves this page.
Why a complete medical provider list matters for a disability claim
Social Security decides a disability claim from medical records, and it can only request records from providers it knows about. Its rules call for your complete medical history covering at least the 12 months before the month you apply. A clinic you forgot to list is a gap in that history, and a gap is one of the easier things to fix early.
Approximate dates are fine. “Spring 2025” tells someone where to look. Fill in what you know and leave the rest blank.
Sources: 20 CFR 404.1512; SSA-3368, Disability Report, Adult.
Medical Provider Organizer
| Provider or clinic | What you see them for | Phone | First visit (about) | Last visit (about) |
|---|---|---|---|---|
| Hospital | Reason | Dates (about) |
|---|---|---|
| Test (MRI, X-ray, blood work) | Where it was done | Date (about) |
|---|---|---|
Using the provider list at each disability claim stage
Before you apply, this list feeds the medical section of the application. After a denial, compare it against the providers named in the notice; anyone missing is worth adding at reconsideration. The After a Denial guide walks through that comparison.
Talk with Downard & Associates about your claim
Downard & Associates represents adults with SSDI and SSI claims in every state by phone and video, from applications through Appeals Council review. Sending an inquiry starts a conversation; it does not file anything with Social Security. We respond to inquiries within 3 business hours.
Representation before Social Security nationwide: 42 U.S.C. 406; 20 CFR 404.1705.