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Residual Functional Capacity Form. Patient: _____ SS #: _____ Date of Birth:_____ Dear Doctor:_____ Please respond to the following questions regarding your patient¶s disability. This will be used as medical evidence for a 6ocial ecurity disability claim or a private long6 term disability claim. MENTAL RESIDUAL FUNCTIONAL CAPACITY ASSESSMENT NAME SOCIAL SECURITY NUMBER CATEGORIES (From IB of the PRTF) ASSESSMENT IS FOR: 12 Months After Onset: Current Evaluation Date Last (Date) Insured: (Date) Other: to (Date) I. SUMMARY CONCLUSIONS This section is for recording summary conclusions derived from the evidence in file. Each mental. MENTAL RESIDUAL FUNCTIONAL CAPACITY QUESTIONNAIRE AND LISTINGS. To: Social Security Administration Re: _____ SSN: _____ Please answer the following questions concerning your patient’s impairments. Attach all relevant treatment notes and test results that have not been provided previously to the Social Security Administration.

Ordinarily, RFC is the individual's maximum remaining ability to do sustained work activities in an ordinary work setting on a regular and continuing basis, and the RFC assessment must include a discussion of the individual's abilities on that basis. A "regular and continuing basis" means a 8 hours a day, for 5 days a week, or an equivalent work schedule. Form SSABK () ef () (Formerly SSAU8 Use prior editions) Page 1 Insured: (Date) PRIVACY ACT NOTICE: The information requested on this form is authorized by Section and Section of the Social Security Act. The information provided will be used in making a decision of this claim. Failure to complete this form may. Downloadable RFC for Adult and Child Mental and Physical Residual Functional Capacity Forms. 24hrs. Contact Us.

MENTAL RESIDUAL FUNCTIONAL CAPACITY ASSESSMENT NAME SOCIAL SECURITY NUMBER CATEGORIES (From IB of the PRTF) ASSESSMENT IS FOR: 12 Months After Onset: Current Evaluation Date Last (Date) Insured: (Date) Other: to (Date) I. SUMMARY CONCLUSIONS This section is for recording summary conclusions derived from the evidence in file. RFC assessment forms are a permanent part of the disability record and are filed on the left side of the folder, under the SSAU5, SSAU5, or SSAU5. 3. Court actions. Downloadable RFC for Adult and Child Mental and Physical Residual Functional Capacity Forms. 24hrs. Contact Us.