Form SSA-5072 Request for Medical Treatment in SSA Facility: Patient S

Form Approved
OMB No. 0960-XXXX

Social Security Administration

REQUEST FOR MEDICAL TREATMENT IN SSA FACILITY:
PATIENT SELF-ADMINISTERED OR STAFF-ADMINISTERED
Personal
Information

Work
Information

Medical
Information

EMPLOYEE NAME

LAST FOUR DIGITS OF SSA NUMBER

HOME ADDRESS

HOME PHONE

ADDRESS

PHONE

SUPERVISOR'S NAME

SUPERVISOR'S PHONE

DIAGNOSIS

MEDICAL TREATMENT

MODE OF ADMINISTRATION

FREQUENCY

EXPECTED END DATE OF
TREATMENT

POTENTIAL ADVERSE REACTIONS

(To Be Completed
By The Employee's
Personal Health Care DATE OF NEXT
APPOINTMENT
Provider)

IS THIS TREATMENT TO BE ADMINISTERED BY THE SSA NURSING STAFF
OR SELF-ADMINISTERED BY THE EMPLOYEE IN THE SSA FACILITY?
SELF-ADMINISTERED

ADMINISTERED BY NURSING STAFF

RECOMMENDATIONS OR REMARKS

*NOTE: THIS REQUEST FOR TREATMENT MUST BE COMPLETED BEFORE TREATMENT CAN BE ADMINISTERED.

PHYSICIAN'S NAME PHYSICIAN'S SIGNATURE
(PRINTED)

SSA Medical
Authorization

EMERGENCY
PHONE

DATE

REMARKS

MEDICAL OFFICER NAME (PRINTED)

Form SSA-5072 (XX-2007)

MEDICAL OFFICER SIGNATURE

DATE

PRIVACY ACT
Under the provision of P.L. 93-579 (Privacy Act) you are advised that Public Law 658, 79th Congress,
dated August 8, 1946, Bureau of Budget Circular A-72, dated June 18, 1976, authorizes the Social
Security Administration to collect the personal information requested on this form. Your response is
voluntary.
The information you provided will be used principally for administering medical treatment as
requested by your private physician. This information may also be used for maintaining your health
record in Employee Health Service.
If you do not provide the required information, Employee Health Service will be unable to provide the
requested service.
Information regarding Disclosure of Your Social
Security Number Under Public Law 93-579 Section 7 (b)
Disclosure by you of your Social Security Number (SSN) is mandatory to obtain the services, benefits
or processes that you are seeking. Solicitation of the SSN by the Social Security Administration is
authorized under provisions of Executive Order 9397, dated November 22, 1943. The SSN is used as
an identifier throughout your Federal career from the time of application through retirement. It will be
used primarily to identify your records that you file with the Social Security Administration and the
Civil Service Commission. The SSN also will be used by the Social Security Administration and the
Civil Service Commission in connection with lawful requests for information about you from your
former employers, educational institutions, and financial or other organizations. The information
gathered through the use of the number will be used only as necessary in personnel administration
processes carried out in accordance with established regulations and published notices of systems of
records. The SSN also will be used for the selection of persons to be included in statistical studies of
personnel management matters. The use of the SSN is made necessary because of the large number of
present and former Federal employees and applicants who have identical names and birth dates, and
whose identities can only be distinguished by the SSN.

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 5 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 Blvd,
Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not
the completed form.

Form SSA-5072 (XX-2007)