6 NC LRD Authorization to Release Information Form

OMB Number: 0915-0140

Expiration Date: xx/xx/xxxx

Public Burden Statement:

The purpose of the Nurse Corps Loan Repayment Program (Nurse Corps LRP ) is to assist in the recruitment and retention of professional Registered Nurses (RNs), including Advanced Practice Registered Nurses (APRNs), dedicated to working in health care facilities with a critical shortage of nurses or working as nurse faculty in eligible schools of nursing, by decreasing the economic barriers associated with pursuing careers at such critical shortage facilities or in academic nursing. 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 0915-0140 and it is valid until x/x/xxx. This information collection is required to obtain or retain a benefit (Section 846 of the Public Health Service Act, as amended (42 U.S.C. 297n). Public reporting burden for this collection of information is estimated to average 0.7 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].

Nurse Corps Loan Repayment Program

U.S. Department of Health and Human Services

Health Resources and Services Administration

NURSE CORPS LOAN REPAYMENT PROGRAM (NURSE CORPS LRP) AUTHORIZATION to RELEASE INFORMATION

As a Nurse Corps Loan Repayment (Nurse Corps LRP) applicant/participant, , hereby authorize:

(print full name)

1. The HHS, 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 Nurse Corps LRP, and to determine the eligibility of my educational loans for repayment under the Nurse Corps LRP: my name, address(es), social security number, account number(s), account status, and other information necessary to identify me.

2. Any program or entity to which I owe a service obligation, or defaulted on a service obligation, to release information relating to that obligation to HHS and/or its contractors.

This authorization will take effect on the date that I sign this release form. If I become a participant in the Nurse Corps LRP, this authorization shall remain in effect until the date my Nurse Corps LRP obligation, including any extension of the obligation pursuant to a continuation contract has been fulfilled or this authorization is revoked by me in writing. If I do not become a participant in the Nurse Corps LRP, this authorization shall remain in effect, one year from the date authorization is signed and dated.

Signature of Applicant Date

Authorization to Release Information Form

This form authorizes HHS, and/or its contractors, to release information that identifies the applicant for purposes of obtaining the applicant’s educational loan information. It also authorizes any program to which the applicant owes a health professions service obligation to release information to HHS and/or its contractors.