Universal Service - Rural Health Care Program/Rural Health Care Pilot Program

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Approved by OMB

3060—0804

Estimated time per response: 1 hour

Updated April 2008

Form 466-A Instructions

Rural Health Care Universal Service Mechanism

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PURPOSE OF FORM

The Form 466-A is used by health care providers (HCP) and their authorized representatives to request

the benefit of reduced rates for Internet service from the Rural Health Care Division (RHCD) of the

Universal Service Administrative Company (USAC). An HCP must submit one Form 466-A for each

Internet Service Provider (ISP). Form 466-A is also used by applicants eligible under the FCC’s

December 15, 2004 Order on Reconsideration for Rural Health Care to request support of advanced

telecommunications and Internet services in states that are “entirely rural”. (Currently only American

Samoa, the US Virgin Islands, the Northern Marianas, and Guam meet this qualification). One Form 466-

A must be completed for each service.

FILING REQUIREMENTS AND GENERAL INSTRUCTIONS

Who Must File

Only the HCP or its authorized representative may file the Form 466-A.

HCPs cannot receive support directly from the Universal Service Fund. Rather, HCPs may receive

the benefit of reduced rates for Internet service from their selected Internet Service Provider, who

will be compensated for those reduced rates by the Universal Service support mechanism.

When to File

Beginning with Funding Year 2004 (July 1, 2004-June 30, 2005), the FCC has set the June 30

th

end

of the funding year as the deadline by which all Form 466-As must be submitted. RHCD cannot

accept Form 466-As for a funding year after the June 30

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end of that funding year.

Although RHCD will accept Form 466-A and accompanying documentation at any time during the funding

year, an HCP should strive to submit its Form 466-A during the “Form Filing Window.” The “Form Filing

Window” is a period during which all Forms 466-A received by RHCD will be treated as if they had arrived

on the first day for purposes of funding priority. The opening and closing dates of the Form Filing Window

are announced each year on the RHCD website. Forms received after the close of the Form Filing

Window will be processed and prioritized according to the date of receipt by RHCD. RHCD will continue

to accept and process Forms 466-A throughout the funding year, until RHCD reaches the annual funding

cap established by the FCC.

Please note that there are certain prerequisites to completing Form 466-A. The HCP or its authorized

representative must select the service provider before completing Form 466-A. However, in order to

satisfy the FCC’s competitive bidding requirement, an HCP must wait at least 28 days after the

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Rural Health Care Pilot Program Participants should consult the 2007 Rural Health Care Pilot Program Selection

Order, WC Docket No. 02-60, Order, 22 FCC Rcd 20,360 (2007) (2007 RHC PP Selection Order), available at

http://www.fcc.gov/cgb/rural/rhcp.html, concerning form completion and related program requirements. Additional

information concerning the Rural Health Care Pilot Program is available on the Universal Service Administrative

Company’s (USAC) website at http://www.universalservice.org/rhc-pilot-program/default.aspx and on the Federal

Communications Commission’s website at http://www.fcc.gov/cgb/rural/rhcp.html.

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descriptions set forth in the HCP’s Form 465

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are posted on the RHCD website, before signing a

contract or otherwise selecting the service provider. RHCD will send a “Receipt Acknowledgement

Letter” to each applicant who submits a Form 465 for the current funding year. This letter will expressly

identify the earliest date (Allowable Contract Selection Date) on which the HCP may sign an agreement

or otherwise select the ISP.

Where to File

A paper copy of Form 466-A with an original signature or an E-Cert Form 466-A must be submitted for

each location’s Internet service. (See RHCD website, www.usac.org/rhc/

, for instructions on Electronic

Certification of Form 466-A.) Each Form 466-A must be accompanied by all necessary attachments.

Applicants are encouraged to complete Form 466-A on the RHCD website, but unless the applicant has

been approved for E-Certification, a Form 466-A completed on the website MUST BE PRINTED,

SIGNED, and SUBMITTED to the address below.

Forms and attachments should be sent to:

Rural Health Care Division

30 Lanidex Plaza West, P.O.Box 685

Parsippany, NJ 07054-0685

DO NOT FILE THIS OR ANY UNIVERSAL SERVICE FORM WITH THE FEDERAL COMMUNICATIONS

COMMISSION.

Compliance

Anyone filing false information may be subject to penalties for false statements, including fine or

forfeiture, under the Communications Act, 47 U.S.C. 502, 503(b), or fine or imprisonment under Title 18

of the United States Code, 18 U.S.C. 1001.

Where to Get More Information

Call RHCD at 1-800-229-5476 for more information on how to complete this and other universal service

forms. Information is also available on the RHCD’s website at www.usac.org/rhc/

.

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The FCC Form 465 is the first form that the HCP or its authorized representative filed with the RHCD in order to

receive telecommunications and/or Internet service at reduced rates.

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SPECIFIC INSTRUCTIONS

Type or print clearly in spaces provided. Attach additional sheets if necessary.

Block 1: HCP Information

Block 1 will help the applicant and RHCD identify each Form 466-A filed.

Line 1 requires providing the health care provider (HCP) name. This name must be used consistently on

all universal service forms (i.e., Forms 465, 466, 466-A and 467). The HCP name should match the HCP

name in Line 3 of Form 465.

Line 2 requires providing the HCP number. The HCP number is a unique identifier given by RHCD to

each HCP applying for support. RHCD will assign an HCP number to each new applicant upon receipt of

the Form 465. The HCP number entered on Line 2 must match the HCP number in Line 1 of the

associated Form 465.

Line 3 requires providing the Form 465 Application Number. The Form 465 Application Number should

match the Form 465 Application Number at the top of Form 465 as it appears posted on the RHCD

website, www.usac.org/rhc/.

Line 4 requires providing the name of the consortium, if the HCP is a consortium member. Leave Line

5 blank if the HCP is not a consortium member. If an HCP belongs to more than one consortium, it may

have different points of contact, different connections, and different billing numbers. In such a case, it is

essential that different consortia names and different Bill Payer Information be provided to avoid

processing delays.

Block 2: Bill Payer Information

Line 5 requires providing the billed entity’s name. The “billed entity” is the entity that actually pays the

bills of the service provider for the HCP. It may be the HCP itself, or it may be a “parent” organization or

consortium to which the HCP belongs.

Line 6 requires providing the Billed Entity’s FCC Registration Number (FCC RN). All participants in the

RHCD program must obtain an FCC RN. Information on how to get an FCC RN is available on the FCC

website at www.fcc.gov.

Line 7 requires providing the name of a contact person at the billed entity location. This person should

be able to answer questions or verify the information submitted on this form, in the event that RHCD

needs to contact the billed entity during the application process.

Lines 8-15 require providing the contact person’s mailing address, city, state, ZIP code, telephone

number, fax number, and E-mail address.

Block 3: Funding Year Information

Line 16 requires indicating the funding year (July 1 through June 30) for which the HCP is requesting

support. Check ONLY one box. This information should match the information in Block 3 Line 26 of the

Form 465 for the same funding year.

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Block 4: Service Information

Line 17 requires providing a brief description of the service for which support is requested.

For purposes of the Rural Health Care program, the Federal Communications Commission (FCC) defines

eligible Internet access as “an information service that enables rural health care providers to post their

own data, interact with stored data, generate new data, or communicate over the World Wide Web.”

Transmissions must traverse the Internet in some fashion. Internal connections, computer equipment or

other telecommunications equipment, even when used to access the Internet, are not eligible for support.

Examples of eligible Internet services can be found on the RHCD website at www.usac.org/rhc/.

HCPs seeking support of advanced telecommunications and Internet services in states that are “entirely

rural” (currently only American Samoa, the US Virgin Islands, the Northern Marianas, and Guam) should

use this section to describe the advanced telecommunications or Internet service, including bandwidth,

for which they seek support.

Line 18 requires entering the percentage of the service used by the HCP (in Line 17 above) for the

provision of health care.

If the percentage of service used for the provision of health care is less than 100%, describe briefly in the

lines below how the percentage was derived (time of use, number of uses, bandwidth used, etc.).

Line 19 requires providing the location where the service is being provided. This location should be the

HCP’s physical address.

Line 20 requires providing the full legal name of the selected service provider.

Line 21 requires entering the 9-digit Service Provider Identification Number (SPIN) for the service

provider listed in Line 20 above. The HCP’s service provider should provide its SPIN upon request.

Line 22 requires providing the account number that the service provider has created to bill for the service.

This information will help the service provider apply the credit to the proper account. If there are multiple

account numbers, provide one main number. If the service has been established, an account number

should be found on past bills or the applicant may request the account number from the service provider.

If the service provider has not yet established an account number for a new service, the applicant should

ask the service provider for a “pre-account” identifier for the service, and use that identifier.

Line 23 requires providing a contract number or other contract identifier, if the HCP has signed a contract

with the selected service provider. If there is no contractual agreement, “NA” should be entered in Line

23. If there is a contractual agreement, a copy of a contract is required.

Line 24 requires identifying the date (mm/dd/yyyy) the HCP or its authorized representative entered into

an agreement with a service provider, or the date the HCP or its authorized representative otherwise

selected the service provider. For instance, this may be the date the HCP or its authorized representative

signed a contract.

The HCP or its authorized representative must not select a service provider or enter into a contract or

purchase agreement with a service provider until at least 28 days have elapsed after the descriptions set

forth in Form 465 are posted on the RHCD website. This is the Allowable Contract Selection Date

(ACSD). An HCP with existing service may continue to receive (non-supportable) service during the 28-

day posting period, but must not select a service provider to continue the service beyond the ACSD until

the ACSD. Entering into an agreement prior to the ACSD could disqualify the HCP from receiving

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benefits under the universal service support mechanism for services under those agreements.

Line 25 requires entering the date (mm/dd/yyyy) the date the contract expires. Enter “NA” if there is no

contractual agreement.

Line 26 requires listing the date the HCP expects service to start, or the date of installation. If service has

already started, enter the date it started.

Line 27 requires confirmation of whether or not the HCP received bids for the services requested. If so,

copies of the bids must be mailed to RHCD,

30 Lanidex Plaza West, P.O.Box 685, Parsippany, NJ 07054-0685. For

identification purposes, write the HCP number on the first page of each bid copy.

Block 5: Cost of Service

Line 28 requires entering the rate charged for the installation of the service described in Line 17, if

applicable. If service was installed before the Allowable Contract Selection Date, the HCP is not eligible

to receive installation support. This rate may include taxes and regulatory fees incurred in obtaining

services.

Line 29 requires entering the amount the HCP pays per month, or the amount the HCP expects to pay

per month, for the service. This information should be taken from the service provider’s bill, or from the

new service offer or contract the HCP received from the service provider. This amount may include taxes

and regulatory fees required to receive the service. The submitted document must be dated, and the date

must be within the funding year for which support is requested. A copy of the bill, contract, service

offer, or a letter from the service provider, from which this information was obtained, must be

mailed to RHCD, 30 Lanidex Plaza West, P.O.Box 685, Parsippany, NJ 07054. For identification purposes,

write the HCP number on the first page of each copy.

Block 6: Certification

Line 30 requires certification that the HCP or its authorized representative has considered all bids

received (see Line 27) in response to RHCD’s website posting of the HCP’s Description of Services

Requested and Certification Form (FCC Form 465). Line 30 also requires the applicant to certify that the

HCP or its authorized representative has selected the most cost-effective method of providing the

requested service(s). The most cost-effective service is defined in the FCC’s Universal Service Order

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as

the method that costs the least after consideration of the features, quality of transmission, reliability, and

other factors that the HCP deems relevant to choosing a method of providing the required health care

services.

Line 31 requires certification that the HCP satisfies each of the specific requirements set forth in the

Form 466-A and its instructions, and that the HCP will abide by the relevant requirements of 47 U.S.C. §

254.

Line 32 requires certification that the billed entity will maintain complete billing records for the service

provided to the HCP at reduced rates. Such records will be needed if the HCP is subject to an audit, and

should be retained for five years from the last day of the funding year. Service providers shall also retain

documents related to the delivery of discounted telecommunications and supported services for at least

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Federal-State Joint Board on Universal Service, CC Docket No. 96-45, Report and Order, 12 FCC Rcd 8776, 9134

(1997) (Universal Service Order) (subsequent history omitted).

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five years after the last day of the delivery of discounted services.

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Line 33 requires certification that the person signing the Form 466-A is authorized to submit the

information contained in the Form 466-A on behalf of the HCP, and that the information contained in the

Form 466-A is true to the best of his/her knowledge, information, and belief. Persons willfully making

false statements on this form may be punished by fine, imprisonment, or forfeiture under federal law.

Line 34 requires the authorized person to sign his/her name to certify all of the information contained in

Form 466-A and any attachments.

Line 35 requires the authorized person signing to identify the date that the Form 466-A was signed.

Line 36 requires the printed name of the authorized person signing Form 466-A.

Line 37 requires the authorized person signing to identify his/her title or position.

Line 38 requires the name of the organization employing the signer of Form 466-A.

Line 39 requires the FCC RN of the organization employing the signer of Form 466-A.

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.

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47 C.F.R. § 54.619(d); Comprehensive Review of the Universal Service Fund Management, Administration, and

Oversight, WC Docket Nos. 05-195, 02-60, 03-109, CC Docket Nos. 96-45, 02-6, 97-21, Report and Order, 22 FCC

Rcd 16372, 16385, at para. 26 (2007) (Comprehensive Review Report and Order).

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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.