Application and Statement

Status: Original and derived artifacts are available for this document.

Download: pdf

Form SSA-3192 (04-2024)
Discontinue Prior Editions
Social Security Administration

Page of
OMB No. 0960-0624

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 and contractors with disabilities, as defined by section 501(g) of the Rehabilitation Act of 1973, as amended, and 29
U.S.C. 791. To be eligible for the reasonable accommodation of medical parking, you must have a physical, mental, or cognitive
impairment that substantially limits your ability to get from your vehicle to your duty station.
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 degree of your impairment. Your physician's office should directly submit Form
SSA-3193 and accompanying documentation, by a separate fax/facsimile to Director, Office of Security Administration and Project
Management at (410)-597-0455 or in a sealed envelope to P.O. Box 17789, Baltimore, MD 21235-7789. Your physician's office
should avoid sending content that is not relevant to your request for medical parking.
Employees and contractors with plainly obvious physical impairments do not need to submit Form SSA-3193 or medical
documentation and should contact the Medical Parking Office directly at (410) 966-8814 or email to
[email protected].

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.

Privacy Act Statement - Collection and Use of Personal Information

See Revised
The Federal Property and Administrative Services Act of 1949, as amended, 63 Statute 377, 390 (40 U.S.C. 471;
41 CFR Act
Privacy
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
Statement
provide is voluntary. However, failure to provide the requested information may make it impossible for us to process
Attached
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 (04-2024)

Page of

1. Name (Last, First, Middle Initial):

2. Last four digits of SSN:

3. Office/Company:

4. Work Schedule:

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

6. Room No.:

7. Do you currently have a medical
parking permit?

8a. Area:

Yes

8. If yes to 7, identify
current parking:

8b. Lane:

8c. Space:

No

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:

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 Security
Administration and Project Management, and the contract physician. I have
read and understand all of the information provided in the instructions to
this application.
Date:

Telephone Number:

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:
Parking and Credentialing Office
6401 Security Blvd.
Robert M. Ball, 1501
Baltimore, MD 21235-6301
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.