Form 3E NHSC S2S LRP Authorization to Release Information Form.p

OMB No: 0915-0146
Expiration Date: xx/xx/xxxx
Bureau of Health Workforce
U.S. Department of Health and Human Services
Health Resources and Services Administration

National Health Service Corps Students to Service Loan Repayment Program
AUTHORIZATION TO RELEASE INFORMATION FORM
If I become a participant in the National Health Service Corps Student to Services Loan Repayment Program (NHSC S2S LRP), I
, hereby authorize:
(Print Name - Last, First, Middle Initial)
1) The school where I am/was enrolled while participating in the NHSC S2S LRP Program 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, leaveof-absence, withdrawal, or dismissal from school. This information will be used by DHHS to determine my eligibility to
continue to receive NHSC S2S LRP Program benefits and the amount of those benefits.
2) If applicable, I hereby authorize any postgraduate 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
postgraduate 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 Program obligation
to disclose to DHHS, and/or its contractors, information pertaining to my compliance with the NHSC S2S LRP Program
service 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 Program and shall remain in
effect until the date my NHSC scholarship 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. If I do not
become a participant, this authorization shall remain in effect until September 30, 202x.
These authorizations may be revoked by me in writing at any time.

(Signature of Individual)

(Date)

Please upload the completed and signed form to the NHSC SP Online Application: My BHW Account
From questions on how/where to submit this form please contact the Customer Center at: 1-800-221-9393

Public Burden Statement: The purpose of this information collection is to obtain information through the National Health Service Corps Students to
Service Loan Repayment Program (NHSC S2S LRP), which is used to assess an applicant’s eligibility and qualifications for the NHSC S2S LRP. Clinicians
interested in participating in the NHSC S2S LRP must submit an application to the NHSC SP through the My BHW online portal. 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 Office of Management and
Budget control number. The Office of Management and Budget control number for this information collection is 0915-0146 and it is valid until xx/xx/xxxx.
This information collection is required to obtain or retain a benefit [Section 338B of the Public Health Service Act (42 USC 254l-1), as amended; Section
331(i) of the Public Health Service Act (42 USC 254d(i)), as amended)]. 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 Health Resources and Services Administration Reports Clearance Officer, 5600
Fishers Lane, Room 14NWH04, Rockville, Maryland 20857.