2 Privacy Act Release Authorization Form

National Health Service Corps
Loan Repayment Program
U.S. Department of Health and Human Services
Health Resources and Services Administration

OMB No. 0915-0127
Exp. Date: xx/xx/xxxx

NATIONAL HEALTH SERVICE CORPS LOAN REPAYMENT PROGRAM
PRIVACY ACT RELEASE AUTHORIZATION
I,

, residing at
, am an applicant/participant to the National Health Service Corps (NHSC)
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 NHSC
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 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].