SSA-5072 (current)

Form Approved
OMB 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)
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 (07-2014)

Expiration Date:

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.
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)