Form 1 Authorization to Release Information Form

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, I

_, hereby authorize:
(print full name)

i.

The 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.

ii. 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 until
September 30, 2013.

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. It also authorizes any program to which the applicant owes
a health professions service obligation to release information to HHS and/or its contractors.

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OMB No. 0915-0140 Expiration 04/30/2014