Tip for Insurer-specific

Mental health disabilities are evaluated on functional limitations, not just diagnoses — describe how symptoms affect daily life

Tip for Insurer-specific

Include all mental health conditions: depression, anxiety, PTSD, bipolar, etc.

Tip for Insurer-specific

Have your mental health provider complete a separate medical source statement detailing your limitations

Social Security DisabilityhardDoctor signature required

Mental Health / Cognitive Limitations Form

Insurer-specific · Disability Insurance Carriers

Specific assessment of psychiatric/cognitive limitations including concentration, persistence, social functioning, and adaptation. Completed by treating psychiatrist or psychologist.

Form Details

Total fields: 45
Auto-fillable: 25 (56%)
Time without BeneFill: 40 minutes
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Time saved: 30 minutes
Filled by: doctor
Frequency: per incident

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Where to Submit This Form

📬

Return to SSA or the disability insurer that sent it

Some forms may be completed online through your insurer's portal.

🏢

Discuss with your mental health provider during an appointment

Filing Deadline

Typically within 30 days of receipt.

Required Attachments

📎 Completed questionnaire detailing mental health symptoms and functional impacts
📎 Mental health treatment records from psychiatrist, psychologist, or therapist
📎 Medication list and history of mental health treatments tried

Processing Time

Part of the disability claim — reviewed alongside all other evidence.

What Happens Next

SSA or the insurer will use this to evaluate mental health limitations in understanding, remembering, concentrating, interacting with others, and adapting to changes.

Tips for This Form

✓ Mental health disabilities are evaluated on functional limitations, not just diagnoses — describe how symptoms affect daily life
✓ Include all mental health conditions: depression, anxiety, PTSD, bipolar, etc.
✓ Have your mental health provider complete a separate medical source statement detailing your limitations

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10-page report requiring detailed descriptions of all jobs held in the past 15 years including physical demands, tools used, supervision, and lifting requirements.

Function Report

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10-page functional assessment covering ADL capacity, daily routines, social functioning, cognitive abilities, and physical limitations.

Authorization to Disclose Information

SSA-827 · SSA

Authorization allowing SSA to collect medical and other information from providers, hospitals, and other sources for disability determination.

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Disclaimer: BeneFill™ provides form-filling assistance and informational guidance only. It is not affiliated with, endorsed by, or sponsored by the Disability Insurance Carriers or any government agency. The information provided is for general informational purposes and does not constitute legal, medical, financial, or tax advice. Always verify form requirements and submission details directly with the issuing agency.