3 Authorization to Release Information Form

Faculty Loan Repayment Program

Fiscal Year 2021 Supplemental Form Authorization to Release

OMB No. 0915-0150 Expiration: TBD

Public Burden Statement

The purpose of this information collection is to obtain information through the Faculty Loan Repayment Program (FLRP), which is used to assess an applicant’s eligibility and qualifications for the FLRP. 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 0915-0150 and it is valid until xx/xx/2021. This information collection is required to obtain or retain a benefit (Section 738(a) of the Public Health Service Act (42 USC 293b (a)). Public reporting burden or 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].

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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