Privacy Act Release Authorization Form

The National Health Service Corps (NHSC) Loan Repayment Program

OMB: 0915-0127

IC ID: 181468

Information Collection (IC) Details

View Information Collection (IC)

Privacy Act Release Authorization Form
 
No Modified
 
Required to Obtain or Retain Benefits
 
42 CFR 621

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction 2 Privacy Act Release Authorization Form FY13 NHSC LRP Privacy Act Release Authorization Form.pdf Yes Yes Fillable Fileable

Health Illness Prevention

The Public Health Service and National Health Service Corps Health Care Provider Records System  58 FR 12968

100 0
   
Individuals or Households
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 100 0 -5,075 0 0 5,175
Annual IC Time Burden (Hours) 10 0 -508 0 0 518
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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