Form 0127-4 Authorization to Release Info

National Health Service Corps
Loan Repayment Program
U.S. Department of Health and Human Services
Health Resources and Services Administration

AUTHORIZATION TO RELEASE INFORMATION FORM
NATIONAL HEALTH SERVICE CORPS LOAN REPAYMENT PROGRAM

___________________________________________________________________________________________,
(Print Name – First, Middle, Last)
As a National Health Service Corps (NHSC) Loan Repayment Program (LRP) applicant, I hereby authorize:
1. The United States Department of Health and Human Services (HHS), and/or its contractors, to release the
following information to a consumer reporting agency (credit bureau) to obtain a credit report to assess my
eligibility, creditworthiness and suitability to participate in the NHSC LRP and to verify my educational loans: my
name, address(es), social security number, and other information necessary to identify me.
2. The HHS, and/or its contractors, to release the following information to the lenders/holders of my educational
loans in order to obtain loan payoff balances, to determine my eligibility/qualifications to participate in the NHSC
LRP, and to determine the eligibility of my educational loans for repayment under the NHSC LRP: my name,
address(es), social security number, account number(s), account status, and other information necessary to
identify me.
3. The HHS, and/or its contractors, to release my name, address(es) and social security number for the purpose of
determining whether I appear on the Excluded Parties System List.
4. The HHS, and/or its contractors, to release my name, address(es) and social security number for the purpose of
obtaining the National Practitioner Data Bank and Healthcare Integrity and Protection Data Bank Reports to
assess my professional competence and conduct.
5. Any program to which I owe a service obligation to release information relating to that obligation to HHS and/or its
contractors.
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, including any extension of the obligation pursuant to contract extensions and amendments, 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, 2011. The authorization may be revoked by me in writing at any time.

_________________________________________________________ ______________________
(Signature of Applicant)
(Date)

_________________________________________________________
(Please Print Name)
(Revised 05/09 – DAA, BCRS, HRSA, DHHS)

NHSC LRP Forms

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National Health Service Corps
Loan Repayment Program
U.S. Department of Health and Human Services
Health Resources and Services Administration

PRIVACY ACT RELEASE AUTHORIZATION FORM
NATIONAL HEALTH SERVICE CORPS LOAN REPAYMENT PROGRAM

I, ___________________________________, residing at _____________________________
_____________________________________, am an applicant to the National Health Service Corps
(NHSC) Loan Repayment Program (42 U.S.C. 254l-1). I hereby authorize the Department of Health
and Human Services, and/or its contractors, to disclose any information contained in its files relating
to my application to participate in the NHSC Loan Repayment Program to:
_____________________________
(Individual)

_____________________________________
(Relationship / Name of Firm)
_____________________________________
(Address)
_____________________________________
(City, State, Zip Code)

This authority shall remain in effect until September 30, 201, or until this authorization is revoked by
me in writing, whichever occurs first.
I certify that I am the above-named applicant. I understand that the knowing and willful request for, or
acquisition of, information pertaining to an individual from an agency under false pretenses is a
criminal offense under the Privacy Act, subject to a $5,000 fine (5 U.S.C. 552a(i)(3)).
___________________________________
(Signature of Applicant)

__________________
(Date)

I certify that I am the above-named individual, to whom the applicant has authorized disclosure. I
understand that the knowing and willful request for, or acquisition of, information pertaining to an
individual from an agency under false pretenses is a criminal offense under the Privacy Act, subject to
a $5,000 fine (5 U.S.C. 552a(i)(3)).
__________________________________
(Signature of Individual)

NHSC LRP Forms

___________________
(Date)

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