Pediatric Specialty LRP Authorization for Disclosure of Loan Information Form

Substance Use Disorder Treatment and Recovery (STAR) Loan Repayment Program (LRP)

OMB: 0906-0058

IC ID: 260334

Information Collection (IC) Details

View Information Collection (IC)

Pediatric Specialty LRP Authorization for Disclosure of Loan Information Form
 
No New
 
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 6 Pediatric Specialty LRP Auth for Disc of Loan Info Form PS LRP Auth for Disc of Loan Info Form.docx Yes Yes Fillable Fileable

Health Health Care Services

 

500 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 500 0 500 0 0 0
Annual IC Time Burden (Hours) 250 0 250 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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