Form SSA-3192 Application and Statement

OMB No. 0960-0624

Social Security Administration

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 section 501(g) of the Rehabilitation Act of 1973, as amended, 29 U.S.C. 791(g).
Specifically, you must have a physical or mental impairment that substantially limits your mobility or ability to walk to be eligible
for the reasonable accommodation of medical parking.
In support of your application for medical parking, your physician must submit Form SSA-3193 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,via a separate fax/facsimile to the Director, Office of Protective Security Services at
(410)-597-0455 or sealed envelope 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 Medical Parking Office 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 Medical Parking Office at (410) 966-8814.
Application and Statement
in Connection With the Medical Parking at SSA Headquarters
Building in Baltimore, MD
Privacy Act Statement
Collection and Use of Personal Information
The Federal Property and Administrative Services Act of 1949, as amended, 63 Statute 377, 390 (40 U.S.C. 471; 41 CFR
101-20.104-2) and section 501(g) of the Rehabilitation Act of 1973, as amended, 29 U.S.C. 791(g) authorize us to collect this
information. We will use the information you provide to help us determine reasonable accommodations. The information you
provide is voluntary. However, failure to provide the requested information may make it impossible for us to process your
request.
We rarely use the information you provide on this form for any purpose other than for the reasons explained above. However, we
may use it for the administration and integrity of Social Security programs. We may also disclose information to another person or
to another agency in accordance with approved routine uses, which include but are not limited to the following:
1. To enable a third party or an agency to assist Social Security in establishing rights to Social Security benefits and/or
coverage;
2. To comply with Federal laws requiring the release of information from Social Security records (e.g., to the Government
Accountability Office, General Services Administration, National Archives Records Administration, and the Department of
Veterans Affairs);
3. To make determinations for eligibility in similar health and income maintenance programs at the Federal, State, and local
level; and
4. To facilitate statistical research, audit, or investigative activities necessary to assure the integrity of Social Security
programs.
We may also use the information you provide in computer matching programs. Matching programs compare our records with
records kept by other Federal, State, or local government agencies. Information from these matching agencies can be used to
establish or verify a person's eligibility for Federally-funded or administered benefit programs and for repayment of payments or
delinquent debts under these programs.
A complete list of routine uses for this information is available in our Systems of Records Notices entitled, Social Security
Administration Parking Management Record System, 60-0230, and Reasonable Accommodation for Persons with Disabilities
(RAPD) 60-0315. The notices, additional information regarding this form, and information regarding our system and programs,
are available on-line at www.socialsecurity.gov or at any local Social Security office.
Form SSA-3192 (04-2014)

1. Name (last, first, middle intial):
3. Office/Company:

2. Last four digits of SSN:
4. Work Schedule:

5. Building/Entrance No.(ex. Robert M. Ball, Entrance 12):

6. Room No.:

8b. Lane:
8a. Area:
7. Do you currently have a medical 8. If yes to 7,
YES
NO
parking permit?
identify current parking:
9. Briefly describe your physical or mental impairment for which you seek medical parking:

8c. Space:

10. Briefly describe why you believe that you need medical parking:

YOUR PHYSICIAN MUST ALSO SUBMIT FORM SSA-3193 PHYSICIAN'S REPORT AND SUPPORTING
DOCUMENTATION. FAILURE TO SUBMIT THE REPORT AND DOCUMENTATION MAY PROHIBIT THE
AGENCY FROM PROCESSING YOUR REQUEST.
Applicant's
Authorization
and Certification
Signature:

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 Director, Office of Protective Security Services, and
the contract physician. I have read and understand all of the information
provided in the instructions to this application.
Date:
Telephone no.:

SUBMISSION INSTRUCTIONS: 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:
Director, Office of Protective Security Services
Social Security Administration
P.O. Box 17789
Baltimore, MD 21235-7789
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 (OMB) control number. The OMB
control number for this collection is 0960-0624. We estimate that it will take between 30 minutes to read the
instructions, gather the facts, and answer the questions. Send only comments relating to our time
estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.
Form SSA-3192 (04-2014)