SSA-5072 -- Bi-Annual Submission

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

Documents and Forms

Document Name Document Type
SSA-5072 - Revised PA and PRA Statements.pdf Other-Revised Privacy Act and PRA St
SSA-5072 Request for Medical Treatment in an SSA Facility: Self-A SSA-5072 - Revised Version.pdf Form
SSA-5072 - Current Version.pdf Current SSA-5072 IC Document

Information Collection (IC) Details

IC Title:	SSA-5072 -- Bi-Annual Submission	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 75	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Previously Approved
Annual Number of Responses for this IC	150	150
Annual IC Time Burden (Hours)	13	13
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.