Form SSA-3193 Physician's Report

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

PHYSICIAN’S REPORT In Connection With Medical Parking at SSA Headquarters in Baltimore, MD
Section A – To Be Completed By The Applicant
1. Name (last, first, middle int.):		2. Last four digits of SSN:
Applicant’s Authorization to Release Medical Documentation	I authorize the release to authorized Social Security Administration (Agency or SSA) officials, including the Deputy Director, Office of Protective Security Services and contract Public Health Service physician, of any and all information or records connected with my application for medical parking.
	Signature:		Date:
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. 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. 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.
Section B – To Be Completed By The Physician
INSTRUCTIONS: 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, the employee must have a physical or mental impairment that substantially (severely) limits their mobility or ability to walk to be eligible for the reasonable accommodation of medical parking. Deleted sentence. You, the physician, must complete this form as support for your patient’s application for SSA medical parking. For your patient to be eligible for this accommodation, he/she must have a physical or mental impairment that substantially limits the individual’s ability to walk, as substantiated by both clinical notes from the individual’s medical record, as well as by objective medical documentation such as X-ray reports, MRI report, pulmonary function tests, or other medical testing results. Failure to provide the needed information could result in SSA denying your patient’s application.

1. Patient’s Name (last, first, middle int.):			2. Last four digits of SSN:
3. Diagnosis of patient’s physical or mental impairment for which medical parking is sought.
4. Injury date, if applicable:			5. Surgery date, if applicable:
6. Date of last examination/ appointment:	7. Date of next examination/ appointment:		8. Expected duration of condition:
9. Prognosis and current treatment, including medications, physical therapy, and other active management.
10. If you have directed this patient to use an ambulating assistance device, please state which kind.
Medical documentation required with this form: Copies of the two most recent physician office notes, concerning this patient’s impairment (please delete any information not pertaining to the impairment for which medical parking is sought). Copies of any diagnostic reports relevant to determining the severity of this patient’s impairment; for example, Cardiac Impairments– recent ETT, ECHO, or cardiac procedure report; Pulmonary Impairments – recent spirometry report or chest x-ray report; and Degenerative Joint Impairments – recent x-ray report or MRI report.
Physician’s Printed Name		Address
Telephone Number		Signature		Date
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: Deputy Director, Office of Protective Security Services Social Security Administration P.O. Box 17789 Baltimore, MD 21235-7789 If you have any questions, you should contact the Deputy Director at (410) 966-8814.
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 the physician about 90 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.