3 STAR LRP Privacy Act Release Authorization Form

Privacy Act Release Authorization

PEDIATRIC SPECIALTY LOAN REPAYMENT PROGRAM

U.S. Department of Health & Human Services

Health Resources and Services Administration

OMB #: 0906-0058

Expiration Date: xx/xx/xxxx

I, , residing at

, am an applicant/participant to the Pediatric Specialty 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 PS Loan Repayment Program to:

(Individual) (Relationship/Name of Firm)

(Address)

(City, State, Zip Code)

This authority shall remain in effect one year from the date that the authorization is signed and dated, 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)

Public Burden Statement: The purpose of this information collection is to obtain performance data for the following: HRSA program participant, program operations, and applications.  In addition, these data will facilitate the ability to demonstrate alignment between BHW discretionary programs and the Substance Use Disorder Treatment and Recovery Loan Repayment and the Pediatric Specialty Loan Repayment programs. 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 0906-0058 and it is valid until xx/xx/xxxx. This information collection is required to obtain or retain a benefit Section 781 of the Public Health Service Act (42 U.S.C. § 295h) and Section 775 of the Public Health Service Act (42 U.S.C. § 295f). Public reporting burden for this collection of information is estimated to average xx hour 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].

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	MCones-HRSA
File Modified	0000-00-00
File Created	2023-08-25