2 Authorization to Release Information Form

Faculty Loan Repayment Program

Fiscal Year 2018 Supplemental Form Authorization to Release

OMB No. 0915-0150 Expiration: TBD

Public Burden Statement

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a current OMB control number. The information is being collected and will be used to evaluate an applicant’s eligibility, qualifications, and suitability for participating in the FLRP. Public reporting burden for this collection of information is estimated to average XXX hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Disclosure of information sought is voluntary; however, if not submitted, except for questions related to Race/Ethnicity on the online application, an application will be considered incomplete and therefore will not be considered for an award. The information applicant’s supply will be maintained in a system of records and subject to disclosure under the Privacy Act Notification Statement in the FLRP Application and Program Guidance. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Office, 5600 Fishers Lane, Room 14N39, Rockville, Maryland 20857.

Faculty Loan Repayment Program

U. S. Department of Health and Human Services Health Resources and Services Administration OMB No. 0915-0150, Expiration: TBD

FACULTY LOAN REPAYMENT PROGRAM AUTHORIZATION to RELEASE INFORMATION

As a Faculty Loan Repayment Program (FLRP) applicant/participant, I _, hereby authorize:

1. The HHS Secretary, and/or its contractors, to release the following information to the lenders/holders of my educational loans in order to determine my eligibility/qualifications to participate in the FLRP, and to determine the eligibility of my educational loans for repayment under the FLRP: my name, address(es), social security number, account number(s), account status, and other information necessary to identify me.

2. The HHS Secretary, and/or its contractors, to release my name, address(es) and social security number for the purpose of determining whether I appear on the Excluded Parties System List.

3. Any program to which I owe a health professions service obligation to release information relating to that obligation to the HHS Secretary and/or its contractors.

4. The HHS Secretary, and/or its contractors, to release the following information to the educational institution where I am/will be employed as a faculty member to assess my eligibility to participate in the FLRP, and, if selected to participate in the FLRP, my compliance with the FLRP service obligation: name, social security number and other identifying information.

5. The educational institution at which I am/will be employed as a faculty member to release information relating to my employment status (e.g., date of employment, number of hours worked, absences from work, position held, etc.) to HHS Secretary and/or its contractors, for purposes of determining my eligibility to participate in FLRP and, if I am selected to participate in FLRP, my compliance with the FLRP service requirements.

This authorization will take effect on the date I sign this release. If I am a participant in the FLRP, this authorization shall remain in effect until the date my FLRP obligation has been fulfilled. If I do not become a participant in the FLRP, this authorization shall remain in effect until September 30^th of the fiscal year in which it was signed or until this authorization is revoked by me in writing, whichever occurs first.

Signature of Applicant Date

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