2 Authorization for Disclosure of Loan Information Form

Public Burden Statement: The purpose of this information collection is to obtain performance data for the following: HRSA program participant, program operations, and applications.  In addition, these data will facilitate the ability to demonstrate alignment between BHW discretionary programs and the Substance Use Disorder Treatment and Recovery Loan Repayment and the Pediatric Specialty Loan Repayment programs. 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 collection is required to obtain or retain a benefit Section 781 of the Public Health Service Act (42 U.S.C. § 295h) and Section 775 of the Public Health Service Act (42 U.S.C. § 295f). Public reporting burden for this collection of information is estimated to average xx hour 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 14N136B, Rockville, Maryland, 20857 or paperwork@hrsa.gov.

OMB #: 0906-0058

Expiration Date: xx/xx/xxxx

Pursuant to the Right to Financial Privacy Act of 1978 (RFPA) (12 U.S.C. 3404), having read the statement of my RFPA rights below, 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 Pediatric Specialty 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, please call the Customer Care Center, 1-800-221-9393, Monday through Friday, from 8:00 a.m. to 8:00 p.m. EST.