3 Authorization for Disclosure of Loan Information Form

Authorization for Disclosure of Loan Information
LOAN REPAYMENT PROGRAM
OMB No: 0915-0127
Exp. Date: xx/xx/xxxx

Pursuant to the Right to Financial Privacy Act of 1978 (RFPA) (12 U.S.C. 3404), and the Fair Credit Reporting Act (FCRA), having read the
statement of my RFPA rights, I hereby authorize the government agencies or financial institutions and credit bureaus to release financial
records and/or credit reports to the HHS for the purpose of assessing and verifying loan amounts, history of honoring prior legal obligations and
eligibility of the educational loans for payment under the HHS. This authorization is valid for 3 months from the date of my signature, and
may be revoked in writing at any time before my records are disclosed.

Name of Applicant – please print

Applicant’s Signature

Date

STATEMENT OF CUSTOMER RIGHTS UNDER THE RIGHT TO FINANCIAL PRIVACY ACT OF 1978
Federal law protects the privacy of your financial records. Before banks, savings and loans associations, credit unions, credit card issuers, or
other financial institutions may give financial information about you to a Federal Agency, certain procedures must be followed.

Consent To Disclosure
You may be asked to consent to a financial institution making your financial records available to the Government. You may withhold your
consent, and your consent is not required as a condition of doing business with any financial institution. If you give your consent, it can be
revoked in writing at any time before your records are disclosed. Furthermore, any authorization you provide is effective for only three
months, and your financial institution must keep a record of the instances in which it disclosed your financial information.

Disclosure Without Your Consent
Without your consent, a Federal Agency that wants to see your financial records may do so ordinarily only by means of a lawful subpoena,
summons, search warrant, or formal written request for that purpose.
Generally the Federal Agency must give you advance notice of its request for your records explaining why the information is being sought
and telling you how to object in court. The Federal Agency must also send you copies of court documents to be prepared by you with
instructions for filling them out. While these procedures will be kept as simple as possible, you may want to consult an attorney before
making a challenge to a Federal Agency request.

Exceptions
In some circumstances, a Federal Agency may obtain financial information about you without advance notice or your consent. In most of
these cases, the Federal Agency will be required to go to court for permission to obtain your records without giving you notice beforehand.
In these instances, the court will make the Government show that its investigation and request for your records are proper. When the
reason for the delay of notice no longer exists, you will be notified that your records were obtained.

Transfer Of Information
Generally, a Federal Agency which obtains your financial records is prohibited from transferring them to another Federal Agency unless it
certifies in writing that the transfer is proper and sends a notice to you that your records have been sent to another Agency.

Penalties

If a Federal Agency or financial institution violates the Right to Financial Privacy Act, you may sue for damages or to seek compliance with
the law. If you win, you may be repaid your attorney’s fees and costs.

Additional Information

If you have additional questions about your rights under this law or how to consent to the release of your financial records, you may contact the
Customer Care Center at 1-800-221-9393.
Public Burden Statement:
The purpose of this information collection is to obtain information through the National Health Service Corps Loan Repayment Program that is used to assess a Loan
Repayment Program applicant’s eligibility and qualifications for the Loan Repayment Program, or for NHSC Site Application and Recertification purposes. Clinicians
interested in participating in the National Health Service Corps Loan Repayment Program must submit an application to the National Health Service Corps. 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 0915-0127 and it is valid until xx/xx/xxxx. This information collection is required to obtain or retain a benefit (Section 333 [254f] (a)
(1) of the Public Health Service Act). The information is protected by the Privacy Act, but it may be disclosed outside the U.S. Department of Health and Human Services,
as permitted by the Privacy Act and Freedom of Information Act, to Congress, the National Archives, and the Government Accountability Office, and pursuant to court
order and various routine uses as described in the System of Record Notice 09-15-0037. Public reporting burden for this collection of information is estimated to average
approximately 30 minutes 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 14N39, Rockville, Maryland, 20857 or [email protected].

5600 Fishers Lane
Rockville, MD 20857

NHSC.hrsa.gov