Information Collection

SSA-5072 -- Bi-Annual Submission

IC 181617 under ICR 201701-0960-004 · OMB 0960-0772.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0772 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-5072 Request for Medical Treatment in SSA Facility: Patient Self-Administered or Staff-Administered SSA-5072 -- Bi-Annual Submission	Form
SSA-5072 Request for Medical Treatment in SSA Facility: Patient S SSA-5072 (revised).pdf	Form
SSA-5072 (current).pdf SSA-5072 (current)	IC Document

IC Title:

SSA-5072 -- Bi-Annual Submission

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-5072				No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 75

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	150	150
Annual IC Time Burden (Hours)	13	13
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-5072 (current)		01/17/2017

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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