1 Authorization to Release Information Form

Faculty Loan Repayment Program
Fiscal Year 2015
Supplemental Form
Authorization to Release
To apply to the Faculty Loan Repayment Program, you must submit your online application, forms, and
supporting documents to http://www.hrsa.gov/loanscholarships/repayment/faculty/forms.pdf. Applications
that are mailed or faxed will not be accepted.

Please note that several supporting documents will need to be completed online as part of the FLRP online
application. Additional forms that must be uploaded (in a PDF format) and require an applicant’s signature,
are included in this Supplemental Forms package.
Questions? Call 1-800-221-9393 (TTY: 1-877-897-9910) Monday through Friday (except Federal
holidays) from 8:00 AM to 8:00 PM, ET.

OMB No. 0915-0150 Expiration: 10/31/2015
Public Burden Statement
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a current OMB control number. The
information is being collected and will be used to evaluate an applicant’s eligibility, qualifications, and suitability for participating in the FLRP. Public reporting
burden for this collection of information is estimated to average 6 hours per response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information. Disclosure of information sought is voluntary; however, if
not submitted, except for questions related to Race/Ethnicity on the online application, an application will be considered incomplete and therefore will not be
considered for an award. The information applicant’s supply will be maintained in a system of records and subject to disclosure under the Privacy Act Notification
Statement in the FLRP Application and Program Guidance. 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 Office, 5600 Fishers Lane, Room 11A-33, Rockville, Maryland 20857.

Faculty Loan Repayment Program
U. S. Department of Health and Human Services
Health Resources and Services Administration
OMB No. 0915-0150, Expiration: 10/31/2015

FACULTY LOAN REPAYMENT PROGRAM
AUTHORIZATION to RELEASE INFORMATION
As a Faculty Loan Repayment Program (FLRP) applicant, I
i.

_, hereby authorize:

The HHS, and/or its contractors, to release the following information to the lenders/holders of my
educational loans in order to determine my eligibility/qualifications to participate in the FLRP, and to
determine the eligibility of my educational loans for repayment under the FLRP: my name, address(es),
social security number, account number(s), account status, and other information necessary to identify me.

ii. The HHS, and/or its contractors, to release my name, address(es) and social security number for the purpose
of determining whether I appear on the Excluded Parties System List.
iii. Any program to which I owe a health professions service obligation to release information relating to that
obligation to HHS and/or its contractors.
iv. The HHS, and/or its contractors, to release the following information to the educational institution where I
am/will be employed as a faculty member to assess my eligibility to participate in the FLRP, and, if selected
to participate in the FLRP, my compliance with the FLRP service obligation: name, social security number
and other identifying information.
v. The educational institution at which I am/will be employed as a faculty member to release information
relating to my employment status (e.g., date of employment, number of hours worked, absences from work,
position held, etc.) to HHS and/or its contractors, for purposes of determining my eligibility to participate in
FLRP and, if I am selected to participate in FLRP, my compliance with the FLRP service requirements.
This authorization will take effect on the date I sign this release. If I become a participant in the FLRP, this authorization
shall remain in effect until the date my FLRP obligation has been fulfilled. If I do not become a participant in the FLRP,
this authorization shall remain in effect until September 30, 2015. This authorization may be revoked by me in writing
at any time.

Signature of Applicant

Date

2