SSA-5072 Request for Medical Treatment in an SSA Facility: Self-A

Revisions to the form highlighted in yellow

Form SSA-5072 (01-2019)
Discontinue Prior Editions
Social Security Administration

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OMB No. 0960-0772

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:
Building:

City, State:
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 SSA Medical Office)
Approved

Denied

Date:

Medical Office Reviewer (printed):
Signature:
Remarks:

For SSA EHC nurse use only:

Expiration Date:

Form SSA-5072 (01-2019)

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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. See Revised Privacy Act Statement Attached
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.

See Revised PRA Attached
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.