Request for Medical Treatment in an SSA Facility: Self-Administered or Staff Administered Care

OMB 0960-0772

OMB 0960-0772

SSA's Employee Health Clinic (EHC) provides emergency care, treatment of on-the-job illnesses and injuries, and health care for employees with chronic medical conditions and allergies who require allergy antigens. SSA also permits employees to use the EHC for self-administration of medical treatments for a chronic health condition. SSA collects information on Form SSA-5072 to approve or deny requests for medical treatment in an SSA EHC. The respondents are the private physicians of the SSA employees seeking medical treatment in an SSA EHC.

The latest form for Request for Medical Treatment in an SSA Facility: Self-Administered or Staff Administered Care expires 2021-01-31 and can be found here.

OMB Details

SSA-5072 -- Annual Submission

Federal Enterprise Architecture: Health - Health Care Services

Form SSA-5072Request for Medical Treatment in SSA Facility: Patient Self-Administered or Staff-AdministeredPaper OnlyForm

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