Form SSA-3193 Physician's Report

Social Security Administration

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 initial.):

2. Last four digits of SSN:

I authorize the release to authorized Social Security Administration (Agency or SSA) officials,
including the Director, Office of Protective Security Services and contract physician, of any
Applicant's Authorization and all information or records connected with my application for medical parking.
to Release Medical
Documentation
Signature:
Date:
Physician's Report in Connection With Medical Parking at SSA Headquarters 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 and 41 CFR
101-20.104-2); 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.

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.
Form SSA-3193 (04-2014)

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
section 501(g) of the Rehabilitation Act of 1973, as amended, 29 U.S.C. 791(g). Specifically, the employee must have a physical
or mental impairment that substantially limits their mobility or ability to walk to be eligible for the reasonable accommodation of
medical parking.
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 two most recent 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.
REQUIRED MEDICAL DOCUMENTATION 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.
1. Patient's Name (last, first, middle initial.):

2. Last four digits of SSN:

3. Diagnosis of patient's physical or mental impairment for which medical parking is sought.

5. Surgery date, if applicable:

4. Injury 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.
I declare under penalty of perjury that I have examined all the information on this form and on any accompanying
statement or forms, and it is true and correct to the best of my knowledge.
Physician's Printed Name:
Address:

Telephone Number:

Signature:

Date:

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
If you have any questions, you should contact the Medical Parking Office 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 (OMB) control number. The OMB control number for this collection is 0960-0624. We estimate that it
will take between 90 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-3193 (04-2014)