Private Practice Option Form

The National Health Service Corps (NHSC) Loan Repayment Programs

OMB: 0915-0127

IC ID: 209461

Documents and Forms
Information Collection (IC) Details

View Information Collection (IC)

Private Practice Option Form
 
No Modified
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction 4 Private Practice Option Form Private Practice Option Form.docx Yes Yes Fillable Fileable

Health Health Care Services

 

330 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 330 0 0 0 0 330
Annual IC Time Burden (Hours) 33 0 0 0 0 33
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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