Form 6 NC LRD Authorization to Release Information Form

OMB Number: 0915-0140

Expiration Date: xx/xx/xxxx

Nurse Corps Loan Repayment Program

U.S. Department of Health and Human Services

Health Resources and Services Administration

NURSE CORPS LOAN REPAYMENT PROGRAM (NURSE CORPS LRP) AUTHORIZATION to RELEASE INFORMATION

As a Nurse Corps Loan Repayment (Nurse Corps LRP) applicant/participant, , hereby authorize: (print full name)

1. The U.S. Department of Health and Human Services (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 Nurse Corps LRP, and to determine the eligibility of my educational loans for repayment under the Nurse Corps LRP: my name, address(es), social security number, account number(s), account status, and other information necessary to identify me.

2. My current, former, or future employer or the health care facility or school of nursing where I work as an RN or nurse faculty to disclose information pertaining to my employment status to the HHS, and/or its contractors, for purposes of determining my eligibility to participate in the Nurse Corps LRP and, if I am selected to participant in the Nurse Corps LRP, to determine my compliance with the Nurse Corps LRP service requirements. “Information pertaining to my employment status” includes, but is not limited to, my salary, dates of employment, number of hours worked, position held, leave hours/records, nurse licensure data, or the existence of a service obligation to my employer or the health care facility or school of nursing.

3. To assess my eligibility to participate in the Nurse Corps LRP, and if I am selected to participate in the Nurse Corps LRP, to determine my compliance with the Nurse Corps LRP service requirements, I hereby authorize HHS, and/or its contractors, to release the following information to my current, former, or future employer(s) or the health care facility or school of nursing where I work as an RN or nurse faculty: my name, social security number and other information necessary to identify me.

4. Any program or entity to which I owe a service obligation, or defaulted on a service obligation, to release information relating to that obligation to HHS and/or its contractors.

This authorization will take effect on the date that I sign this release form. If I become a participant in the Nurse Corps LRP, this authorization shall remain in effect until the date my Nurse Corps LRP obligation, including any extension of the obligation pursuant to a continuation contract has been fulfilled or this authorization is revoked by me in writing. If I do not become a participant in the Nurse Corps LRP, this authorization shall remain in effect, one year from the date authorization is signed and dated.

Signature of Applicant Date

Authorization to Release Information Form
This form authorizes HHS, and/or its contractors, to release information that identifies the applicant for purposes of obtaining the applicant’s educational loan information. This form authorizes the applicant’s employer or the health care facility where he/she works as an RN or nurse faculty to release information regarding the applicant’s employment status to Nurse Corps LRP. It also authorizes HHS, and/or its contractors, to release information to the applicant’s employer or the health care facility where he/she works as an RN or nurse faculty for purposes of determining his/her eligibility and compliance with the service requirements if he/she receives a Nurse Corps LRP award. If the applicant is awarded a Nurse Corps LRP contract, his/her employment status will be verified semiannually. It also authorizes any program to which the applicant owes a health professions service obligation to release information to HHS and/or its contractors.

For questions on how/where to submit this form please contact the Customer Care Center at: 1-800-221-9393.

Public Burden Statement: The purpose of this information collection is to obtain information through the Nurse Corps Loan Repayment Program that is used to assess a Loan Repayment Program applicant’s eligibility and qualifications for the Loan Repayment Program and to monitor a participant’s compliance with the program’s service requirements. Applicants interested in participating in the Nurse Corps Loan Repayment Program must submit an application to the Nurse Corps. 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 0915-0140 and it is valid until xx/xx/xxxx. This information collection is required to obtain or retain a benefit (Section 846 of the Public Health Service Act, as amended [42 U.S.C. 297n]). 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 14NWH04, Rockville, Maryland, 20857.