Physician's Report

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Form SSA-3193 (03-2024)
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Social Security Administration

Page of
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 Security Administration
Applicant's Authorization and Project Management and contract physician, of any and all information
or records connected with my application for medical parking.
to Release Medical
Documentation
Date:
Signature:
Physician's Report in Connection With Medical Parking at SSA Headquarters in Baltimore, MD
Privacy Act Statement
Collection and Use of Personal Information

See Revised Privacy
Act Statement
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
Attached
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 (03-2024)

Page of

Section B - To Be Completed By The Physician
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.
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 reasonable accommodation, he/she must have a physical, mental, or cognitive impairment that substantially
limits his/her ability to get from his/her vehicle to the duty station. The medical documentation must be recent, objective, and clear.
The physician may submit a letter describing the patient's condition(s) and symptom(s) relevant to the need for medical parking,
but it is not sufficient to provide an unsupported conclusory statement that a patient needs medical parking. Do not submit content
that is not relevant to the patient's request for medical parking. 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:
4. Injury date, if applicable:

5. Surgery 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:
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 Security Administration and Project Management
Social Security Administration
Parking and Credentialing Office
6401 Security Blvd.
Robert M. Ball, 1501
Baltimore, MD 21235-6301
If you have any questions, you should contact the Medical Parking Office at (410) 966-8814 or email to
[email protected].
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 about 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.