Form 1 NHSC SP Authorization to Release Information

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

NATIONAL HEALTH SERVICE CORPS SCHOLARSHIP PROGRAM
AUTHORIZATION TO RELEASE INFORMATION

If I become a participant in the National Health Service Corps (NHSC) Scholarship Program, I,
__________________________________________________________, hereby authorize:
(Print Name - First, Middle Initial, Last)
1) The school where I am/was enrolled while participating in the NHSC Scholarship Program 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
scholarship benefits and the amount of those benefits.
2) If applicable, I hereby authorize any postgraduate 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 postgraduate 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 Scholarship
Program obligation to disclose to DHHS, and/or its contractors, information pertaining to my compliance
with the NHSC scholarship service 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 Scholarship Program and
shall remain in effect until the date my NHSC scholarship 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 September
30, 2014.
These authorizations may be revoked by me in writing at any time.

____________________________________ ____________
(Signature of Individual)
(Date)

(Last 4 Digits of
Social Security Number)

Please upload to the NHSC SP Online Application: https://programportal.hrsa.gov/