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

Form Approved
OMB No. 0960-0772

Social Security Administration

Request for Medical Treatment in an SSA Facility
(Self-Administered of Staff-Administered)

Section 1: Employee Information (To be completed by employee)
Name:

Last four digits of SSN:

Home address:
Home phone:

Other phone:

Employee Work Information
Component:

Work phone:

City, State:

Building:

Supervisor's Name:

Office/cubicle:
Supervisor's phone:

Section 2: Medical Treatment (To be completed by the employee's Independent Licensed Health Care Provider)
Treatment being requested (to include dosage, mode of administration, frequency and duration when applicable):

Expected end date of treatment:

Diagnosis (related to requested treatment):

Treatment to be:

Self-Administered

Staff-Administered

Potential Adverse Reactions (related to requested treatment):

Date of next follow-up appointment with provider
requesting treatment:

Recommendations, remarks or other comments:

Independent Licensed Health Care Provider's Name and Address:

Office phone:

Emergency phone:

Signature:

Date:

Section 3: SSA Medical Office Authorization (To be completed by Medical Officer in SSA Medical Office)
Approved

Denied

Date:

Reviewing Medical Officer's Name (printed):
Signature:
Remarks:

For SSA EHC nurse use only:
Form SSA-5072 (xx-xxxx)

Expiration Date:

Privacy Act Statement
Request for Medical Treatment in SSA Facility
Patient Self-Administered or Staff-Administered
5 U.S.C. 7901, as amended, authorizes us to collect this information. The information you provide on
this form is used for administering medical treatment as requested by your private physician, and for
maintaining health records in the Employee Health Service. Your response is voluntary. However,
failure to provide the requested information may adversely affect our ability to administer medical
treatment as required.
revised
We rarely use the information provided on See
this form
for any purpose other than for the reasons
Act
explained above. However, we may use it Privacy
for the administration
and integrity of Social Security
Statement
below.
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 the appropriate Federal, State, or local agency responsible for investigation of an
accident, disease, medical condition, or injury as by pertinent legal authority;
2. To comply with Federal laws requiring the release of information from Social Security
records (e.g., to the Government Accountability Office, the General Services Administration,
the National Archives and Records Administration, and the Department of Justice);
3. To the Office of Worker's Compensation Programs in connection with a claim for benefits
filed by an employee;
4. To facilitate statistical research, audit, and investigative activities necessary to ensure the
integrity and improvement of Social Security programs.
A complete list of routine uses for this information is available in the System of Records Notice
entitled, Employees' Medical Records (60-0237). This notice, additional information about this form,
and information regarding our programs and systems are available on-line at www.socialsecurity.gov
or at your local Social Security Office.

Form SSA-5072 (xx-xxxx)

SSA will insert the following revised PRA Statement into the form at its
next scheduled reprinting:
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. We estimate that it will take about 5
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.

Privacy Act Statement
Collection and Use of Personal Information

5 U.S.C. 7901, as amended, allows us to collect this information. We will use the information
you provide for administering medical treatment as requested by your private physician, and for
maintaining health records in the Employee Health Service.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information may affect our ability to administer medical treatment as required.
We rarely use the information you supply for any purpose other than what we state above,
however, we may use the information for the administration of our programs including sharing
information:
1. To the appropriate Federal, State, or local agency responsible for investigation of an
accident, disease, medical condition, or injury as by pertinent legal authority;
2. To comply with Federal laws requiring the release of information from our records
(e.g., to the Government Accountability Office and Department of Veterans Affairs);
3. To the Office of Worker’s Compensation Programs in connection with a claim for
benefits filed by an employee; and,
4. To facilitate statistical research, audit, or investigative activities necessary to assure
the integrity and improvement of our programs (e.g., to the Bureau of the Census and
to private entities under contract with us).
A complete list of when we may share your information with others, called routine uses, is
available in our Privacy Act System of Records Notice 60-0237, entitled, Employees’ Medical
Records. Additional information about this and other system of records notices and our
programs are available from our Internet website at www.socialsecurity.gov or at your local
Social Security office.
We may share the information you provide to other health agencies through computer matching
programs. Matching programs compare our records with records kept by other Federal, State, or
local government agencies. We use the information from these programs to establish or verify a
person’s eligibility for federally funded or administered benefit programs and for repayment of
incorrect payments or delinquent debts under these programs.