Form 6 PS LRP Auth for Disc of Loan Info Form

OMB No. 0906-0058
Expiration Date: xx/xx/xxxx
Bureau of Health Workforce
U.S. Department of Health and Human Services
Health Resources and Services Administration

SUBSTANCE USE DISORDER TREATEMENT & RECOVERY LOAN REPAYMENT PROGRAM
AUTHORIZATION FOR DISCLOSURE OF LOAN INFORMATION
Pursuant to the Right to Financial Privacy Act of 1978 (RFPA) (12 U.S.C. 3404), having read the statement of my RFPA rights, I hereby
authorize the government or financial institution named below to release financial records relating to the educational loan(s) identified below
to the Bureau of Health Workforce (BHW) and/or its contractors for the purpose of assessing and verifying the amount and eligibility the
educational loan for payment under the Substance Use Disorder Treatment and Recovery Loan Repayment Program. 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 Government or Financial Institution - please print
Applicant's Loan Account Numbers
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 on how/where to submit this form, please call the Customer Care Center, 1-800-221-9393, Monday
through Friday, from 8:00 a.m. to 8:00 p.m. EST.
Public Burden Statement:

The purpose of this information collection is to obtain information through the Substance Use Disorder Treatment and Recovery Loan Repayment Program
(STAR LRP) that is used to assess a Loan Repayment Program applicant’s eligibility and qualifications for the STAR LRP and to obtain information for eligible
facilities or sites. Clinicians interested in participating in the STAR LRP must submit an application to the STAR LRP through the My BHW online portal. 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 is required to obtain or retain
a benefit (Section 781 of the Public Health Service Act [42 U.S.C. § 295h]). 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 xx hours 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 13N82, Rockville,
Maryland, 20857.