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

Form Approved
OMS No. 0960-0772

Social Security Administration

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

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

I

Name:

Last four digits of SSN :

Home address:

I

Home phone:

Other phone:

Employee Work Information
Component:

Work phone:

City, State:

Building:

Office/cubicle:

Supervisor's Name:

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):

Diagnosis (related to requested treatment):

Treatment to be:

D

Expected end date of treatment:

D

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)

D

Approved

D Denied

I

Date:

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

For SSA EHC nurse use only:
Form SSA-5072 (07-2014)

Expiration Date:

Privacy Act Statement
Collection and Use of Personal Information

See Revised Privacy
Act and PRA Statement

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.
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 .

Form SSA-5072 (07-2014)

SSA will insert the following revised Privacy Act Statement into the form as soon
as possible:
PRIVACY ACT STATEMENT
Collection and Use of Personal Information
Section 7901 of Title 5 of the United States Code allows us to collect this information.
Furnishing us this information is voluntary. However, failing to provide all or part of the
information may prevent us from administering or allowing the self-administration of medical
treatment in a Social Security Administration Employee Health Clinic (SSAEHC).
We will use the information you provide to approve or deny requests for self or staffadministered medical treatment in an SSAEHC. We may also share this information for the
following purposes, called routine uses:
1. To the appropriate Federal, State, or local agency responsible for investigation of an
accident, disease, medical condition, or injury as required by pertinent legal authority;
and
2. To the Office of Worker’s Compensation Programs in connection with a claim for
benefits filed by an employee.
In addition, we may share this information in accordance with the Privacy Act and other Federal
laws. For example, where authorized, we may use and disclose this information in computer
matching programs, in which our records are compared to other records to establish or verify a
person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notice (SORN),
60-0237, entitled Employees’ Medical Records. Additional information and a full listing of all
our SORNs are available on our website at www.socialsecurity.gov/foia/bluebook.

SSA will insert the following revised PRA Statement into the form as soon
as possible:
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.