Privacy Act Release Authorization Form

The National Health Service Corps (NHSC) Loan Repayment Programs

OMB: 0915-0127

IC ID: 181468

Information Collection (IC) Details

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Privacy Act Release Authorization Form
 
No Modified
 
Required to Obtain or Retain Benefits
 
42 CFR 621

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction 3 NHSC LRP FY 2020 - Privacy Act Release Authorization Form.pdf NHSC LRP FY 2020 - Privacy Act Release Authorization Form.pdf Yes Yes Fillable Fileable

Health Health Care Services

The Public Health Service and National Health Service Corps Health Care Provider Records System  58 FR 12968

303 0
   
Individuals or Households
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 303 0 28 0 0 275
Annual IC Time Burden (Hours) 30 0 2 0 0 28
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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