Form SSA-3192 Application and Statement

Form Approved
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 Rehabilitation Act of 1973, as amended, 29 U.S.C. 791, et
seq. 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 determining whether the physical or mental
impairment "substantially limits" your ability to walk, SSA will consider: (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.
In support of your application for medical parking, you must submit the attached 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, if required, via a separate sealed envelope or facsimile to the Deputy
Director, Office of Protective Security Services. Employees with plainly obvious physical impairments do not need to
submit the physician's report or medical documentation, and should contact the Deputy Director, Office of Protective
Security Services directly at (410) 966-8814.
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.
1. Name (last, first, middle int.):

2. Last four digits of SSN:

3. Office/Company:

4. Work Schedule:

5. Building:

6. Room No.:

7. Do you currently have a medical parking
permit? ______YES ______NO

8. If yes to 7,
please state:

8a. Area:

8b. Lane:

9. Briefly describe your physical or mental impairment for which you seek medical parking.

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

Form SSA-3192 (X-2008)

Page 1 of 2

8c. Space:

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 Social Security
Administration officials, including the Deputy Director, Office of Protective Security
Services, and the contract PHS physician. I have read and understand all of the
information provided in the instructions to this application.

Date:

Telephone Number:

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
YOU MUST ALSO SUBMIT THE ATTACHED PHYSICIAN'S REPORT AND SUPPORTING
DOCUMENTATION. FAILURE TO SUBMIT THE REPORT AND DOCUMENTATION MAY
PROHIBIT THE AGENCY FROM PROCESSING YOUR REQUEST.
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 for
further explanation as to the reasons why the SSA may use or disclose information about you.
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 30 minutes to read the instructions, gather the facts, and answer the questions. You may send
comments on our time estimate above to: SSA 6401 Security Boulevard, Baltimore, MD 21235-6401. Send
only comments relating to our time estimate to this address, not the completed form.

Form SSA-3192 (X-2008)

Page 2 of 2