Addendum to the Suppporting Statement 0960-0624

Addendum to the Supporting Statement for

Forms SSA-3192, SSA-3193, and SSA-3194

Medical Permit Parking Application Forms

41 cfr 101.20-104.2

omb No. 0960-0624

Revisions to the Collection Instrument

Changes to the SSA-3192, Application and Statement

First page, first paragraph following the heading INSTRUCTIONS:

• Adding text at the end of first sentence to read: “…and the ADA Amendment Act of 2008.”

• Deleting the last sentence that reads: In determining whether the physical or mental impairment “substantially limits” your ability to walk…etc.”

First page, second paragraph following the heading INSTRUCTIONS, updating address information text to read:

• P.O. Box 17789, Baltimore, MD 21235-7789.

Adding the heading HIPAA STATEMENT; adding the following text under HIPAA statement heading:

• 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: moving the Privacy Act Statement from the bottom of the form to under the HIPAA Statement. Updating the Privacy Act Statement language to conform to current agency policies.

Updating telephone number on first page, last paragraph of form to read:

• ..at (410) 966-8814.

Second Page of form, paragraph adjacent to heading Applicant’s Authorization and Certification; changing text to read:

• “…authorized SSA officials, including…and the contract Public Health Service physician.”

Text box above Paperwork Reduction Act Statement:

• Changing text in first sentence to update telephone number to read (410)597-0455.

• Deleting text in first sentence “…or hand-delivered …”

• Updating address to read: P.O. Box 17789, Baltimore, MD 21235-7789.

Updating Paperwork Reduction Act Statement to conform to current agency policies.

Changes to the SSA-3193, Physician’s Report

Under the heading PRIVACY ACT STATEMENT adding the following text:

• “…and the ADA Amendment Act of 2008.”

Under the heading Section B – To Be Completed By The Physician, INSTRUCTIONS

• Adding the following text: “…and the ADA Amendment Act of 2008.”

• Deleting the last sentence: “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.”

Page 2, text block #1, adding the word “Patient’s”

Page 2, last text block above the Paperwork Reduction Act Statement:

• Updating telephone number to read (410)597-0455.

• Updating address to read: P.O. Box 17789, Baltimore, MD 21235-7789.

Updating Privacy Act Statement to conform to current agency policies.

Changes to the SSA-3194, Renewal Certification

Changing the name of the form to: Permanent Medical Parking Renewal Certification.

Changing second text box to read: To be completed only by individuals possessing a medical parking assignment.

Under the heading INSTRUCTIONS:

• Adding text to end of first sentence to read “…and the ADA Amendment Act of 2008.”

• Adding text to second sentence “…SSA provided you with a medical parking assignment, which was…”

• Adding text to end of last sentence “P.O. Box 17789, Baltimore, MD 21235-7789, or fax to (410) 597-0455.

In the paragraph adjacent to the heading Renewal Certification, adding the text “…for a medical parking assignment.” Adding text box for telephone number.

Updating Paperwork Reduction Act language to comply with current agency policies.

Justification – SSA is revising the collection instruments as detailed above to comply with Americans with Disabilities Act requirements, to update Paperwork Reduction Act and Privacy Act Statements, and to improve clarity and readability of the forms.