Form SSA-3192 Application and Statement

[Type text] [Type text] OMB No. 0960-0624

APPLICATION AND STATEMENT In Connection With Medical Parking at SSA Headquarter Buildings in Baltimore, MD
To Be Completed By The Applicant
INSTRUCTIONS: The Social Security Administration (Agency or SSA) offers medical parking as a reasonable accommodation to employees who are “disabled,” as defined by Rehabilitation Act of 1973, as amended, 29 U.S.C. 791, et seq. , and the ADA Amendment Act of 2008. Specifically, you must have a physical or mental impairment that substantially restricts your mobility or ability to walk to be eligible for the reasonable accommodation of medical parking. Deleted sentence. In support of your application for medical parking, you must submit the attached physician’s report and include objective medical documentation supporting the severity of the impairment, such as physician’s office notes, x-ray reports, MRI reports, pulmonary function tests, or other medical testing results. Your physician’s office should directly forward the physician’s report and accompanying documentation, if required, via a separate sealed envelope or facsimile to the Deputy Director, Office of Protective Security Services, P.O. Box 17789, Baltimore, MD 21235-7789. Employees with plainly obvious physical impairments do not need to submit the physician’s report or medical documentation, and should contact the Deputy Director, Office of Protective Security Services directly at (410) 966- 8814. HIPAA STATEMENT: In accordance with the Health Insurance Portability and Accountability Act (HIPAA), Pub. L. 104-191, SSA needs your written authorization in order to obtain the Protected Health Information (“PHI”) required to process your application for Medical Parking. Your authorization will remain valid for 12 months. You may write to SSA or your physician at any time to revoke your authorization, except to the extent a physician has already relied on it to take an action. If you request, SSA will give you a copy of your Application and Statement. You may ask your physician to allow you to inspect the Physician’s Statement. If you have any questions, you should contact the Deputy Director, Office of Protective Security Services at (410) 966-8814. PRIVACY ACT STATEMENT: SSA is authorized to collect the information requested on this form by the Federal Property and Administrative Services Act of 1949, as amended, 63 Statute 377, 390 (40 U.S.C. 471, 486 and 41 CFR 101-20.104-2), and Rehabilitation Act of 1973, as amended, 29 U.S.C. 791, et seq., and the ADA Amendment Act of 2008, Executive Order 9397 (November 22, 1943) authorizes use of the Social Security Number. SSA uses this information to provide standards for apportioning and assignment of handicapped parking spaces on SSA managed, controlled or assigned property, and to allocate and check parking spaces assigned to handicapped personnel and others. SSA also uses it to determine reasonable accommodations. (New location.) You do not have to give SSA this information. Your submission is voluntary. SSA, however, will use the information provided by you to facilitate the processing of your request. Therefore, the failure to fully complete the form and provide the requested information may make it impossible for SSA to process your request. SSA will not make any disclosure of this information to agencies or individuals outside this department unless the law permits, you provide written consent, or it is otherwise required. For example, SSA may disclose the information to the Department of Justice in the event of litigation where the defendant is SSA, any SSA component, or any SSA employee in his or her official capacity; to a congressional office requesting information on your behalf; and to volunteers or individuals working under a service contract and other individuals performing functions for SSA if they need access to the records for the performance of their assigned agency functions. You may contact the Deputy Director, Office of Protective Security Services at (410)966-8814 for further explanation as to the reasons why the SSA may use or disclose information about you.
1. Name (last, first, middle int.):				2. Last four digits of SSN:
3. Office/Company:				4. Work Schedule:
5. Building:				6. Room No.:
7. Do you currently have a medical parking permit? ______YES ______NO			8. If yes to 7, please state:		8a. Area:		8b. Lane:	8c. Space:
9. Briefly describe your physical or mental impairment for which you seek medical parking.
10. Briefly describe why you believe that you need medical parking.
Applicant’s Authorization and Certification	I certify that all statements made above are true to the best of my knowledge and belief. I give my permission for the release of information about the physical or mental conditions(s) for which I seek medical parking to authorized SSA officials, including the Deputy Director, Office of Protective Security Services, and the contract Public Health Service physician. I have read and understand all of the information provided in the instructions to this application.
Signature		Date				Telephone no.
This completed form and accompanying medical reports may be faxed to (410) 597-0455, or mailed in a sealed envelope marked, “Confidential – Medical Parking Information,” to: Deleted Info Deputy Director, Office of Protective Security Services Social Security Administration P.O. Box 17789 Baltimore, MD 21235-7789 YOU MUST ALSO SUBMIT THE ATTACHED PHYSICIAN’S REPORT AND SUPPORTING DOCUMENTATION. FAILURE TO SUBMIT THE REPORT AND DOCUMENTATION MAY PROHIBIT THE AGENCY FROM PROCESSING YOUR REQUEST.
PAPERWORK REDUCTION ACT STATEMENT: This information collection meets the requirements of 44 U.S.C § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget control number. We estimate that it will take about 30 minutes to read the instructions, gather facts, and answer the questions. You may send comments on our time estimate above to: SSA 1338 Annex Building, Baltimore, MD 21235-0001. Send only comments relating to our time estimate to this address, not the completed form.