Medical Consultant's Review of Physical Residual Functional Capacity Assessment

Medical Consultant's Review of Physical Residual Functional Capacity Assessment

SSA-392 AeDIB Screens

Medical Consultant's Review of Physical Residual Functional Capacity Assessment

OMB: 0960-0680

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F m Approved

OMB No.0980-0880

REFERRING DDS
SN OF NUMBER HOLDER

- -

MEDICAL CONSULTANTS REVIEW
OF PHYSICAL RESIDUAL FUNCTIONAL
CAPACITY ASSESSMENT

CLAIMANr'S NAME
DATE(S) SSA-4734-BK APPLICABLE

-

PART A EVALUATION
SHOW AGREE OR DISAGREE WITH EACH SECTION OF THE SSA~MK
BELOW. (Plscuss each disagreement In Part 0 . )

BY CHECKING THE CORRESPONDING ITEMS

-

I. UMlTAllONS (Check "agreen If the DDS conclusions are reasonable and
ruppwted by evldenca In the file.)

I

AGREE

I

DISAGREE

a. EXERTIONAL LIMITATIONS

b. POSTURAL LIMITATIONS

c. MANIPULATIVE LIMITATIONS
d. VlSUAL LIMITATIONS

e. COMMUNICATIVE LIMITATIONS
f.

ENVIRONMENTAL LIMITATIONS

-

II. SYMPTOMS (Chedr "%me" if the DDS dlscussud ator documented
symptoms and agswsed symptMMslatd limltatlons, not Plmady addressed In
Section 1 of #re SSAQ734-BK)

-

Ill. TREATING OR EXAMINING SOURCE STATEMENTS ( C M"m"
If the DDS
dincussed all relevant W n g or examlnlng source atabmmts not alnady
discussed In Sections I or I1 of the SSA47344K.)

-

Cite each item In dispute (lee.,SSA-4734-BK d o n and item number).
For each item cited, show p u t concluskm and explain how and why the evidence supports these conclusions.
Annotate any necessary comments hen.

Form 8811592 (12-2004) d (12-2004) Use 4-2004 edltkn unmR stmly is -ted

(Continued on next page)

Form Selector

Page I of 1

The information rapesled on this form is ~ r l h o r h dby Spction 223 and Section 1633 of the Social S ~ u r i i yAct. The information
plovidcd.will bs uscd in m e i n n decisim q &is claim. Failwe to cunplsts the form may mull in a delay in pmea~insthe claim.
nfa-mn fmuhodn hu
may be aschard by h e social ~ r i l ~dm,n,rtnt,m
y
m amthcr p-n or gouomncnral
ngency ody 9
t
h m p c l to Social Secu? & programs and to cunpb with Fd-1 Iawa requiringthe ekchange of infmation
k w e m Soe~alSmniy and ahor nmc~m.
.

fkn

_

A

-

PART C COlCLWlON
t.

AGREE

2

DlS AGREE (WS SSA47348K is b m d on merit evidence, but conell-iions

h e evldsnee In fb.)

am not reasonableandor suworted by

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next scheduled reprinting..
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