Form 2 FY16 NHSC LRP Privacy Act Release Authorization Form

2013

National Health Service Corps

Loan Repayment Program

U.S. Department of Health and Human Services

Health Resources and Services Administration

NATIONAL HEALTH SERVICE CORPS LOAN REPAYMENT PROGRAM PRIVACY ACT RELEASE AUTHORIZATION

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, 2017, 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) (Date)