Pediatric Specialty LRP Authorization for Disclosure of Loan Information Form

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

Documents and Forms

Document Name Document Type
Form 6 Pediatric Specialty LRP Authorization for Disclosure of Loan Information Form Form and Instruction
Form 6 Pediatric Specialty LRP Authorization for Disclosure of Loan Information Form Form and Instruction
6 Pediatric Specialty LRP Auth for Disc of Loan Info Form PS LRP Auth for Disc of Loan Info Form.docx Form and Instruction
6 Pediatric Specialty LRP Auth for Disc of Loan Info Form PS LRP Auth for Disc of Loan Info Form.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Pediatric Specialty LRP Authorization for Disclosure of Loan Information Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	250	250
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.