OMB No. 0915-0127
Expiration Date:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Resources and Services Administration
Bureau of Clinician Recruitment and Service
National Health Service Corps
Loan Repayment Program
AUTHORIZATION TO RELEASE INFORMATION
Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0915-0127. Public reporting burden for this collection of information is estimated to average 6 minutes per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10-33 Rockville, Maryland, 20857.
As a National Health Service Corps (NHSC) Loan Repayment Program applicant, I, ___________________________________________,
(Print Name – First, Middle, Last)
hereby authorize the Government or Commercial Institution where I have an outstanding educational loan balance to disclose information pertaining to my educational loans to the Department of Health and Human Services, Division of National Health Service Corps (DNHSC). The DNHSC administers the NHSC Loan Repayment Program. “Information pertaining to my educational loans” includes, but is not limited to, my outstanding “Pay Off” balance and whether I have defaulted on my payment obligation.
This authorization will take effect on the date that I sign this release form. If I become a participant in the NHSC Loan Repayment Program, this authorization shall remain in effect until the date my NHSC Loan Repayment Program obligation has been fulfilled. If I do not become a participant in the NHSC Loan Repayment Program, this authorization shall remain in effect until September 30, 2008.
__________________________ ____________ ______________________
(Signature) (Date) (Social Security No.)
| File Type | application/msword |
| File Title | AUTHORIZATION TO RELEASE INFORMATION |
| Author | HRSA |
| Last Modified By | HRSA |
| File Modified | 2007-07-27 |
| File Created | 2007-07-27 |