OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

SSA-5072 -- Bi-Annual Submission

IC 181617 under ICR 202007-0960-005 · OMB 0960-0772.

Documents and Forms
Document Name
Document Type
Other-Revised Privacy Act and PRA St
Form
IC Document
Information Collection (IC) Details

View Information Collection (IC)

SSA-5072 -- Bi-Annual Submission
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form SSA-5072 Request for Medical Treatment in an SSA Facility: Self-Administered or Staff-Administered SSA-5072 - Revised Version.pdf No   Paper Only
Other-Revised Privacy Act and PRA Statement SSA-5072 - Revised PA and PRA Statements.pdf No   Paper Only

Health Health Care Services

 

75 0
   
Private Sector Not-for-profit institutions, Businesses or other for-profits
 
   0 %

  Requested Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 150 0 0 0 0 150
Annual IC Time Burden (Hours) 13 0 0 0 0 13
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Current SSA-5072 SSA-5072 - Current Version.pdf 10/07/2020
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.