SSA-3193 Physician's Report

Form Approved
OMB No. 0960-0624

Social Security Administration

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 officials,
including the Deputy Director, Office of Protective Security Services and
contract PHS 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. 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. 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. In determining whether the physical or mental impairment "substantially limits" their
ability to walk, SSA will consider, among other things: (1) the nature and severity of the impairment; (2) the duration or
expected duration of the impairment; and (3) the permanent or long term impact, or the expected permanent or long-term
impact resulting from the impairment.
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.
Form SSA-3193 (X-2008)

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1. 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:

6. Date of last
examination/appointment:

5. Surgery date, if applicable:

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:

Telephone Number:

Address:

Signature:

Date:

This completed form and accompanying medical reports may be faxed to (410) 965-9676 or mailed or
hand-delivered in a sealed envelope marked, "Confidential - Medical Parking Information" to:
Deputy Director, Office of Protective Security Services
Social Security Administration
P.O. Box 26430, Suite #18
Baltimore, MD 21207
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 about 90 minutes to read the instructions, and answer
the questions. You may send comments on our time estimate above to: SSA 6401 Security Boulevard, e, MD 21235-6401. Send only
comments relating to our time estimate to this address, not the completed form.

Form SSA-3193 (X-2008)

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