Form 3 STAR LRP Program - Privacy Act Release Authorization For

Public Burden Statement: The purpose of this information collection is to obtain information through the Substance Use Disorder Treatment and Recovery (STAR) Loan Repayment Program (LRP), which used to assess a LRP applicant’s eligibility and qualifications for the LRP and to obtain information for STAR site applicants. Clinicians interested in participating in the STAR LRP must submit an application to the STAR to participate in the STAR program, and health care facilities must submit an STAR Site Application to determine the eligibility of sites to participate in the STAR as an approved service site. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is XXXX-XXXX and it is valid until mm/dd/yyyy. This information collection is required to obtain or retain a benefit (Section 333 [254f] (a)(1) of the Public Health Service Act). Public reporting burden for this collection of information is estimated to average xx hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. 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 Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or [email protected].

Substance Use Disorder Treatment and Recovery Loan Repayment Program

U.S. Department of Health and Human Services Health Resources and Services Administration

SUBSTANCE USE DISORDER TREATMENT AND REOVERY LOAN REPAYMENT

PRIVACY ACT RELEASE AUTHORIZATION

I, , residing at

, am an applicant/participant to the Substance Use Disorder Treatment and Recovery Program 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 STAR Loan Repayment Program to:

(Individual) (Relationship/Name of Firm)

(Address)

(City, State, Zip Code)

This authority shall remain in effect until September 30, 2021, 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/Participant) (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)