Form 1 S2S LRP – Authorization to Release Information

Bureau of Clinician Recruitment and Service

U.S. Department of Health and Human Services

Health Resources and Services Administration

National Health Service Corps Students to Service Loan Repayment Program

Authorization to Release Information

If I become a participant in the National Health Service Corps Students to Service Loan Repayment Program

(NHSC S2S LRP), I, _________________________________________________________, hereby authorize:

(Print Name – First, Middle Initial, Last)

1. The school where I am/was enrolled while participating in the NHSC S2S LRP to disclose information pertaining to my school enrollment to the Department of Health and Human Services (DHHS), and/or its contractors. Information pertaining to my school enrollment includes, but is not limited to, my transcripts and grades, academic standing, enrollment and degree status, curriculum and examination requirements for graduation, tuition and fees, leave of absence, withdrawal, or dismissal from school. This information will be used by DHHS to determine my eligibility to continue to receive NHSC S2S LRP benefits.

2. If applicable, I hereby authorize any post-degree advance training program(s), for which I receive a deferment (i.e., approval) from DHHS to complete, to disclose to DHHS, and/or its contractors, information pertaining to my participation in the post-degree advance training program(s) including, but not limited to, my curriculum and examination requirements, status in the program, completion date, leave-of-absence, withdrawal or dismissal from the program.

3. The entity/entities where I am/was approved to provide service in satisfaction of my NHSC S2S LRP obligation to disclose to DHHS and/or its contractors, information pertaining to my compliance with the NHSC S2S LRP requirements. Such information includes, but is not limited to, my practice location(s), practice responsibilities, work schedule or other documentation indicating the hours that I worked and the hours I was away from the site, records relating to my work performance and (if applicable) the circumstances relating to the termination of my employment at the service location.

The above authorizations take effect on the date that I become a participant in the NHSC S2S LRP and shall remain in effect until the date my NHSC S2S LRP commitment has been fulfilled.

In addition, I hereby authorize the DHHS, and/or its contractors, to release my name, address(es) and social security number to see if I appear on the Excluded Parties List System. This authorization takes effect on the date I sign this release form. If I do not become a participant, this authorization shall remain in effect until

July 31, 2014.

These authorizations may be revoked by me in writing at any time.

___________________________________________ ________________________________

(Applicant’s Signature) (Date) (Last 4 Digits of SSN)