FCC Form 466-A Health Care Providers Universal Service, Internet Servic

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Overview

Blocks 1-6
Reminders

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Sheet 1: Blocks 1-6

FCC Form

Health Care Providers Universal Service

Approval by OMB

466 - A

Internet Service Funding Request and Certification Form

3060—0804

(And Advanced Services Funding Request and Certification for Entirely Rural States)

The Deadline to submit this Form is the June 30th End of the Funding Year.

Estimated time per response: 1 hour

Read instructions thoroughly before completing this form. Failure to comply may cause delayed or denied funding.

Block 1: HCP Information

1

HCP Name

2

HCP Number

3

Form 465 Application #

4

Consortium Name (If any)

Block 2: Bill Payer Information

5

Billed Entity Name

6

Billed Entity's FCC RN

7

Contact Name

8

Address Line 1

9

Address Line 2

10

City

11

State

12

Zip

13

Contact Phone #

14

Fax #

15

E-Mail

Block 3: Funding Year Information

16

Funding Year - Check only one box

Year 2005 (7/1/2005-6/30/2006)

Year 2006 (7/1/2006-6/30/2007)

x

Year 2007 (7/1/2007-6/30/2008)

Block 4: Service Information

17

Give a brief description of the service for which support is requested:

18

Percentage of HCP's service used for the provision of health care. (If less than 100%, please explain.)

19

Location where service is provided:

20

Service Provider Name

21

Service Provider Identification Number (SPIN)

22

Billing Account Number

23

Contract Number (NA if no contract)

24

Date contract signed or service selected

25

Contract Expiration Date (NA if no contract)

26

Expected Service Start Date

27

Were bids received in response to Form 465?

Yes

No

If yes, submit copies.

Block 5: Cost of Service

28

Installation Charge (If applicable)

29

Monthly rate charge (Enclose documentation)

Block 6: Certification

30

I certify that the above named entity has considered all bids received and selected the most cost-effective method of providing the

requested service or services. The "most cost-effective service" is defined in the Universal Service Order as the service available at the lowest cost after consideration of the features, quality of transmission, reliability, and other factors that the health care provider deems necessary for the service to adequately transmit the health care services required by the health care provider.

31

Pursuant to 47 C.F.R. Secs. 54.601 and 54.603, I certify that the HCP or consortium that I am representing satisfies all of the requirements

herein and will abide by all of the relevant requirements, including all applicable FCC rules, with respect to universal service benefits provided under 47 U.S.C. Sec. 254. I understand that any letter from RHCD that erroneously states that funds will be made available for the benefit of the applicant may be subject to rescission.

32

I hereby certify that the billed entity requesting reduced rates will maintain complete records for the service for five years.

33

I certify that I am authorized to submit this request on behalf of the above-named Billed Entity and HCP, and that I have examined this

form and attachments and that to the best of my knowledge, information, and belief, all statements of fact contained herein are true.

34

Signature

35

Date

36

Printed name of authorized person

37

Title or position of authorized person

38

Employer of authorized person

39

Employer's FCC RN

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Sheet 2: Reminders

Please remember:

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An applicant may not file a Form 466-A until after signing the contract or otherwise selecting a service provider

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The HCP or its authorized representative must wait at least 28 days from the Form 465 posting date before signing the contract

or otherwise selecting a service provider.

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You must be authorized to provide the information required by Form 466-A on behalf of the HCP, and you must sign and date the form.

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Provide data for all items that apply. Attach additional sheets if necessary. Any attachments to Form 466-A must be clearly labeled.

Persons willfully making false statements on this form can be punished by fine or forfeiture under the Communications Act, 47 U.S.C. Secs. 502,

503(b), or fine or imprisonment under Title 18 of the United States Code, 18 U.S.C. Sec. 1001.

FCC NOTICE FOR INDIVIDUALS REQUIRED BY THE PRIVACY ACT AND THE PAPERWORK REDUCTION ACT

Part 3 of the Commission's Rules authorize the FCC to request the information on this form. The data reported will be used to ensure that health

care providers have selected the most cost-effective method of providing the requested services as set forth in 47 C.F.R. § 54.603(b)(4). The

information will be used by the Universal Service Administrative Company and/or the staff of the Federal Communications Commission, to evaluate

this form, to provide information for enforcement and rulemaking proceedings and to maintain a current inventory of applicants, health care

providers, billed entities, and service providers. No authorization can be granted unless all information requested is provided. Failure to provide all

requested information will delay the processing of the application or result in the application being returned without action. Information requested

by this form will be available for public inspection. Your response is required to obtain the requested authorization.

The public reporting for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions,

searching existing data sources, gathering and maintaining the required data, and completing and reviewing the collection of information. If you

have any comments on this burden estimate, or how we can improve the collection and reduce the burden it causes you, please write to the

Federal Communications Commission, AMD-PERM, Paperwork Reduction Act Project (3060-0804), Washington, DC 20554. We will also accept

your comments regarding the Paperwork Reduction Act aspects of this collection via the Internet if you send them to [email protected]. PLEASE

DO NOT SEND YOUR RESPONSE TO THIS ADDRESS.

Remember - You are not required to respond to a collection of information sponsored by the Federal government, and the government may not

conduct or sponsor this collection, unless it displays a currently valid OMB control number or if we fail to provide you with this notice. This

collection has been assigned an OMB control number of 3060-0804.

THE FOREGOING NOTICE IS REQUIRED BY THE PRIVACY ACT OF 1974, PUBLIC LAW 93-579, DECEMBER 31, 1974, 5 U.S.C. 552a(e)(3)

AND THE PAPEWORK REDUCTION ACT OF 1995, PUBLIC LAW 104-13, OCTOBER 1, 1995, 44 U.S.C. SECTION 3507.

This form should be submitted to:

Rural Health Care Division

80 S. Jefferson Rd.

Whippany, NJ 07981