No medically determinable physical impairment

See Symptoms, Medically Determinable Physical and Mental Impairments, and Exertional and Nonexertional Limitations (Social Security Ruling (SSR) 96-4p) in DI 24515.065).

Non-severe physical impairment(s)

See Sequential Evaluation of Title II and Title XVI Adult Disability Claims in DI 22001.001.

Insufficient evidence for physical impairment(s)

See Disability Case Development for Medical and Other Evidence in DI 22501.001.

Impairment meets or medically equals a physical listing

See Sequential Evaluation of Title II and Title XVI Adult Disability Claims in DI 22001.001).

Reconsideration affirmation

See Affirmation of a Prior Disability Determination in DI 27021.010.

Continuing disability review (CDR) medical evaluation

See Comparison of Symptoms, Signs, and Laboratory Findings in DI 28010.015.

1. Heading

Fill in the claimant’s name and SSN.

2. Period Covered

Indicate the assessment period covered in the evaluation:

• Current evaluation - Onset date through present and the duration requirement has been met, or when the onset is within 12 months of adjudication and the impairment does not preclude substantial gainful activity (SGA) at the time of the assessment.

• Date last insured (DLI) - For Title II cases only, when DLI has expired in the past. Enter the DLI “(Date)” in the space provided.

• 12 months after onset - When duration is an issue, enter the “(Date)” to which you are projecting in the space provided.

• Other period(s) - For any situation not covered by the other three blocks (multiple assessments or closed periods).

3. Subject

Identify which type of medical finding you are documenting. There may be more than one subject for each SSA-416-UF.

4. Assessment

Document the medical evaluation in this section. As appropriate, address the following:

• onset (See DI 25501.200 through DI 25501.470),

• duration (See DI 25505.025 through DI 25505.040),

• Drug Addiction and Alcoholism (DAA) materiality analysis (See Evaluating Cases Involving Drug Addiction and Alcoholism (DAA) SSR 13-2p in DI 90070.041),

• symptom evaluation (See DI 24501.021), and

• closed period (See DI 25510.001 through DI 25510.015).

5. Signoff block “THESE FINDINGS COMPLETE THE MEDICAL PORTION OF THE DISABILITY DETERMINATION”

• MC/PC: If an MC or PC is completing this form, check this box when the evaluation is complete.

• MA: Do not check this box. The Social Security Act (42 U.S.C. 421(h)) authorizes only an MC or PC to complete the medical portion of the case review and any applicable residual functional capacity (RFC) assessment.

• Do not check this block. This block is for MC/PC completion only.

6. Signer’s Role

Check the appropriate box corresponding with your role in the disability determination.

7. Signature instructions

• In all claims, sign your name, enter your office number, print or type your name, identify the page numbers, and date the form.

• MC/PC/MA Specialty Code: Only an MC, PC, or MA will complete this field. Enter the appropriate specialty code found in DI 24501.004.

8. MC/PC/MA Specialty Code

Only an MC, PC, or MA will complete this field. Enter the appropriate specialty code found in DI 24501.004.

An electronic claim completed in eCAT

Complete a “Medical Advisor (416)” Claim Communication. For guidance on adding a Medical Advisor (416) Claim Communication in eCAT, see the most recent eCAT User Guide.

A paper claim

Complete, print, and add Form SSA-416 to the paper Modular Disability Folder (MDF). For further information about the MDF, see DI 70005.005.