Form 10 Authorization To Release Information Form

BUREAU OF HEALTH WORKFORCE

NURSE CORPS SCHOLARSHIP PROGRAM
AUTHORIZATION TO RELEASE INFORMATION

I, __________________________________________________________, hereby authorize:
(Print Name - First, Middle Initial, Last)
1) The school where I am accepted for enrollment/am enrolled/was enrolled while applying for and
participating in the Nurse Corps 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) The entity/entities where I am/was approved to provide service in satisfaction of my Nurse Corps
Scholarship Program obligation to disclose to DHHS, and/or its contractors, information pertaining to my
compliance with the Nursing 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.
3) 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 that I sign this release form. If I do not become a participant, this
authorization shall remain in effect until September 30, 2020. If I become a participant, the above
authorizations shall remain in effect until the date my Nursing Scholarship commitment has been fulfilled.
These authorizations may be revoked by me in writing at any time.

_________________________________
(Signature of Individual)

____________
(Date)

(Last 4 Digits of Social Security Number)

Must be received by April 30, 2020 at 7:30 pm ET.

Please upload to the Nurse Corps SP Portal: https://programportal.hrsa.gov/