FCC Form 466 Universal Service - Rural Health Care Program - Form for

Health Care Providers Universal Service

FCC Form

466

Funding Request and Certification Form

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

Approval by OMB
3060—0804
Estimated time per response: 3 hours

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

Block 1: HCP Information
1 HCP Name
3 Form 465 Application #
Block 2: Bill Payer Information
5 Billed Entity Name

2 HCP Number
4 Consortium Name (If any)
6 Billed Entity FCC RN

7 Contact Name
8 Address Line 1
9 Address Line 2
10 City

11 State

13 Contact Phone #
14 Fax #
15 E-Mail
Block 3: Funding Year Information
16 Funding Year - Check only one box
Year 2011 (7/1/2011-6/30/2012)
X Year 2010 (7/1/2010-6/30/2011)
Block 4: Service Information
17 Type of Service & Circuit Bandwidth (Enclose documentation.)
18 Total Billed Miles

12 Zip

Year 2012 (7/1/2012-6/30/2013)

19 Maximum Allowable Distance (From Form 465)

20 Percentage of HCP's service used for the provision of health care.

(If less than 100%, please explain.)

If the HCP indicated it is a part-time eligible entity (on Form 465), describe method of allocating prorated support.

Connection Information
21 Service Provider Name

Carrier A

Carrier B

Carrier C

Carrier D

22 Service Provider Identification Number (SPIN)
23 Service Provider Contact Person Name
24 Service Provider Contact Person's Phone #
25 Service Provider Contact Person Email
26 Circuit Start Location
27 Circuit Termination Location
28 Billing Account Number
29 Tariff, Contract or other document reference number
30 Date Contract Signed or Date HCP Selected Carrier
31 Contract Expiration Date (mm/dd/yyyy or NA if MTM)
32 Service Installation Date
33 Actual Rural Rate per Month (Enclose Documentation)
34 If you are a consortium member OR have multiple carriers, please attach a Circuit Diagram to show how the sites
interconnect and which carrier(s) provides each circuit segment.
Circuit Diagram included:
Yes
35 Are you a mobile rural health care provider?

Yes

No

No If yes, see instructions and attach a list of all sites to be served.
FCC Form 466
April 2008

IF YOU ARE REQUESTING SUPPORT FOR MILEAGE-BASED CHARGES,
CHARGES COMPLETE BLOCK 5 ONLY AND SKIP BLOCK 66. (PLEASE SEE
INSTRUCTIONS).
COMPARISON, SKIP BLOCK 5 AND
INSTRUCTIONS) IF YOU ARE REQUESTING SUPPORT BASED ON URBAN/RURAL RATE COMPARISON
6 YOUR APPLICATION CANNOT BE PROCESSED IF BOTH BLOCKS ARE COMPLETED.
COMPLETED
COMPLETE ONLY BLOCK 6.
Block 5: Mileage-based Charge Discount Request
Complete
p
this block if yyou
o are seekingg support
s pport
pp for mileage
g (distance-based)
(distance
(
based)) charges
g only.
only Do not enter an
anyy other charges
g in this block
block. Yo
You ma
mayy need
Carrier A
Carrier B
Carrier C
Carrier D
to ask your service provider representative to provide this information.
information
36 Billed
Bill d Circuit
Ci it Miles
Mil
37 Monthlyy Mileage
g Charges
g (Exclude
(
Channel Termination chgs,
chgs
g etc.)
etc )
38 Cost per Mile per Month
If Line 33 equals Line 37, please ensure that ONLY mileage-related charges are included in Line 37. (See instructions.)
Block 6: Comprehensive
p
Rate Comparison
p
Request
q
Complete Block 6 if you have not completed Block 5 and are requesting support for all elements of your telecommunications service necessary for
the provision of health care.
care The information in this block will establish the difference between the urban and rural rates for your requested service.
service
C
Carrier
A
C
Carrier
B
C
Carrier
C
C
Carrier
D
Please call RHCD at 11-800-229-5476
800 229 5476 if you need assistance.
39 One-time
One time Urban Rate Charge
g (in
( selected large
g city)
y)
40 One
One-time
time Rural Rate Charge (in city where HCP is located)
41 Monthly Urban Rate (in selected large city). From RHCD
web
eb site
site:
or Other rate documentation
doc mentation attached
attached:
If your circuit includes charges for mileage over the Maximum Allowable Dist.,
Dist (Line 19)
19), please complete Lines 42 to 44
44. Otherwise
Otherwise, skip to Block 77.
42 Billed Circuit Miles
43 Monthly Mileage Based Charges
44 Cost per Mile per Month
Block 7: Bid Documentation
45 Did you receive any bids in response to the Form 465 Request for Services posted on the RHCD website?
Yes
No
If you checked
h k d yes, copies
i off the
th bids
bid MUST be
b mailed
il d to
t RHCD.
RHCD
Block 8: Certification
46
I certify that the above named entity has considered all bids received and selected the most cost
cost-effective
effective method of providing the
requested service or services
services. The "most cost
cost-effective
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
necessaryy for the service to adequatelyy transmit the health care services required byy the health care provider.
provider
47

Pursuantt to
P
t 47 C.F.R.
C F R Secs.
S
54.601
54 601 andd 54.603,
54 603, I certify
tify that
th t the
th HCP or consortium
ti that
th t I am representing
p
ti g satisfies
ti fi allll off the
th
requirements herein and will abide by all of the relevant requirements,
requirements including all applicable FCC rules
rules, with respect to universal service
b fit provided
benefits
p id d under
d 47 U.S.C.
U S C Sec.
S 254.
254 I understand
d t d that
th t anyy letter
l tt from
f
RHCD that
th t erroneously
ly states
t t that
th t funds
f d will
ill be
b made
d
available for the benefit of the applicant may be subject to rescission.
rescission

48

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

49

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 myy knowledge,
knowledge
g information,
information and belief,
belief all statements of fact contained herein are true
true.
50 Signature
51 Date
52 Printed name of authorized person

53 Title or position of authorized person

54 Employer of authorized person

55 Employer
Employer'ss FCC RN

FCC Form 466
April 2008

Please remember:
Š You must submit one Form 466 for each service (i.e., circuit) for which you request reduced rates. For example:
y If you are requesting reduced rates for two T1 lines, you must submit two Forms 466.
y If you are requesting reduced rates for two ISDN lines & one Frame Relay line, you must submit three Forms 466.
Š If the service described on this form is subject to the 28-day competitive bidding requirement, do not select a carrier or
complete the Form 466 before or during the 28-day posting period.
Š You must provide evidence of the urban rate if you have completed Block 6 and have not used the urban rates from the website.
Š This form, attachments, and supporting documents should be combined in one envelope and sent to the RHCD.
Š If the service described on this form changes (e.g., rate change) during the funding year, you must notify RHCD immediately
and submit a revised Form 466.
Š If you have any questions, call RHCD at 1-800-229-5476.
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 3 hours 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
30 Lanidex Plaza West, P.O.Box 685
Parsippany NJ 07054-0685

FCC Form 466
April 2008