Form 1 FY 2017 NHSC S2S LRP Authorization to Release

Bureau of Health Workforce

U.S. Department of Health and Human Services Health Resources and Services Administration

OMB No.: 0915-0146

Expiration Date: XX/XX/20XX

National Health Service Corps Students to Service Loan Repayment Program

Authorization to Release Information

If I become a participant in the National Health Service Corps Students to Service Loan Repayment Program

(NHSC S2S LRP), I, , hereby authorize: (Print Name – First, Middle Initial, Last)

1) The school where I am/was enrolled while participating in the NHSC S2S LRP to disclose information pertaining to my school enrollment to the Department of Health and Human Services (DHHS), and/or its contractors. Information pertaining to my school enrollment includes, but is not limited to, my transcripts and grades, academic standing, enrollment and degree status, curriculum and examination requirements for graduation, tuition and fees, leave of absence, withdrawal, or dismissal from school. This information will be used by DHHS to determine my eligibility to continue to receive NHSC S2S LRP benefits.

2) If applicable, I hereby authorize any post-degree advanced training program(s), for which I receive a deferment (i.e., approval) from DHHS to complete, to disclose to DHHS, and/or its contractors, information pertaining to my participation in the post-degree advanced training program(s) including, but not limited to, my curriculum and examination requirements, status in the program, completion date, leave-of-absence, withdrawal or dismissal from the program.

3) The entity/entities where I am/was approved to provide service in satisfaction of my NHSC S2S LRP obligation to disclose to DHHS and/or its contractors, information pertaining to my compliance with the NHSC S2S LRP requirements. Such information includes, but is not limited to, my practice location(s), practice responsibilities, work schedule or other documentation indicating the hours that I worked and the hours I was away from the site, records relating to my work performance and (if applicable) the circumstances relating to the termination of my employment at the service location.

The above authorizations take effect on the date that I become a participant in the NHSC S2S LRP and shall remain in effect until the date my NHSC S2S LRP commitment has been fulfilled.

In addition, I hereby authorize the DHHS, and/or its contractors, to release my name, address(es) and social security number to see if I appear on the Excluded Parties List System. This authorization takes effect on the date I sign this release form.

These authorizations may be revoked by me in writing at any time.

(Applicant’s Signature) (Date) (Last 4 Digits of SSN)

Student may upload signed form to the NHSC S2S LRP Online Application: https://programportal.hrsa.gov/

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 currently valid OMB control number. The OMB control number for this project is 0915–0146. Public reporting burden for this collection of information is estimated to average .10 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 14N39, Rockville, MD 20857.