Authorization to Release Information Form

NURSE Corps Loan Repayment Program

Documents and Forms

Document Name Document Type
Form 6 Authorization to Release Information Form Form and Instruction
6 NC LRD Authorization to Release Information Form NC LRP Authorization to Release Information Form.docx Form and Instruction
6 NC LRD Authorization to Release Information Form NC LRP Authorization to Release Information Form.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Authorization to Release Information Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	6	NC LRD Authorization to Release Information Form	NC LRP Authorization to Release Information Form.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 7,100	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	7,100	7,100
Annual IC Time Burden (Hours)	710	710
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.