Form 3 Authorization for Disclosure of Loan Information Form

National Health Service Corps
FY 2013 Loan Repayment Program
U.S. Department of Health and Human Services
Health Resources and Services Administration

2013

AUTHORIZATION FOR DISCLOSURE OF LOAN INFORMATION
Pursuant to the Right to Financial Privacy Act of 1978 (RFPA) (12 U.S.C. 3404), having read the statement of my RFPA rights below, I hereby
authorize the government or financial institution named below to release financial records relating to the educational loan(s) identified
below to the Bureau of Clinician Recruitment and Service and/or its contractors for the purpose of assessing and verifying the amount and
eligibility of the educational loan for payment under the National Health Service Corps Loan Repayment Program. This authorization is
valid for 3 months from the date of my signature, and may be revoked in writing at any time before my records are disclosed.

(Name of Government of Financial Institution – please print)

(Applicant’s Loan Account Numbers)

(Name of Applicant – please print)

(Applicant’s Signature)

(Date)

STATEMENT OF CUSTOMER RIGHTS UNDER THE RIGHT TO FINANCIAL PRIVACY ACT OF 1978
Federal law protects the privacy of your financial records. Before banks, savings and loans associations, credit unions, credit card issuers, or
other financial institutions may give financial information about you to a Federal Agency, certain procedures must be followed.
Consent to Disclosure
You may be asked to consent to a financial institution making your financial records available to the Government. You may withhold your
consent, and your consent is not required as a condition of doing business with any financial institution. If you give your consent, it can be
revoked in writing at any time before your records are disclosed. Furthermore, any authorization you provide is effective for only three
months, and your financial institution must keep a record of the instances in which it disclosed your financial information.
Disclosure without your Consent
Without your consent, a Federal Agency that wants to see your financial records may do so ordinarily only by means of a lawful subpoena,
summons, search warrant, or formal written request for that purpose.
Generally the Federal Agency must give you advance notice of its request for your records explaining why the information is being sought
and telling you how to object in court. The Federal Agency must also send you copies of court documents to be prepared by you with
instructions for filling them out. While these procedures will be kept as simple as possible, you may want to consult an attorney before
making a challenge to a Federal Agency request.
Exceptions
In some circumstances, a Federal Agency may obtain financial information about you without advance notice or your consent. In most of
these cases, the Federal Agency will be required to go to court for permission to obtain your records without giving you notice beforehand.
In these instances, the court will make the Government show that its investigation and request for your records are proper. When the
reason for the delay of notice no longer exists, you will be notified that your records were obtained.
Transfer of Information
Generally, a Federal Agency which obtains your financial records is prohibited from transferring them to another Federal Agency unless it
certifies in writing that the transfer is proper and sends a notice to you that your records have been sent to another Agency.
Penalties
If a Federal Agency or financial institution violates the Right to Financial Privacy Act, you may sue for damages or to seek compliance with
the law. If you win, you may be repaid your attorney’s fees and costs.
Additional Information
If you have any questions about your rights under this law or how to consent to the release of your financial records, you may contact: the
Division of the National Health Service Corps, Bureau of Clinician Recruitment and Service, 5600 Fishers Lane, Room 8-37, Rockville, MD
20857.