Form FCC Form 465 FCC Form 465 Description of Services Requested and Certification Form

FCC Form

₄₆₅

Health Care Providers Universal Service

_{Description of Services Requested & Certification Form}

Approval by OMB

3060-0804

Estimated time per response: 1 hour

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

1 HCP Number 2 Consortium Name

3 HCP Name 4 HCP FCC Registration Number (FCC RN)

5 Contact Name

6 Address Line 1

7 Address Line 2 8 County

9 10 State 11 ZIP Code

15 Is the HCP's mailing address (where correspondence should be c=]Yes, complete Block 2 sent) different from its physical location described in Block 1? c=JNo, go to Block 3.

16 Contact Name 17 Organization

18 Address Line 1

_{19 Address Line 2}

_{21 State 22 ZIP Code}

27 IOnly Te following types of HCPs are eligible. Indicate which category describet the arplicant. (Check only one.) Post-secondary educational institution offering health care Rural health clinic instruction, teaching hospital or medical school

c:=]community health center or health center providing health • c:=]consortium of the above care to migrants

c:=]Local health department or agency c:=]Dedicated ER of rural, for-profit hospital c::::::::Jcommunitv mental health center

^{c::::::::J Not-for-profit hospital c::::::::J Part-time eliqible entity}

28 If consortium, dedicated emergency department, or part-time eligible entity was selected in Line 27, please describe the entity.

29 Please describe the eligible health care provider's telecommunications and/or Internet service needs, so that service providers may bid to provide the services. The description should describe whether video or store and forward consultations will be

_{used, whether large image files or X-rays will be transmitted, the quality of connection needed, or other relevant considerations.}

Block 5: Request for Services

30 Is the HCP requesting reduced rates for:

c:=]Both Telecommunications & Internet Services c=JTelecommunications Service ONLY c:=]lnternet Service ONLY

Block 6: Certification
31 c::::=JI certify that I am authorized to submit this request on behalf of the above-named entitv or entities. that I have examined this request. and that to the best of my knowledqe, information. and belief. all statements of fact contained herein are true.
32 c::::=JI certify that the health care provider has followed any applicable State or local procurement rules.
33 c::::=JI certify that the telecommunications services and/or Internet access charqes that the HCP receives at reduced rates as a result of the HCPs' participation in this proqram. pursuant to 47 U.S.C. Sec. 254 as implemented by the Federal Communications Commission. will be used solely for purposes reasonably related to the provision of health care service or instruction that the HCP is leqally authorized to provide under the law of the state in which the services are provided and will not be sold, resold. or transferred in consideration for money or any other thinq of value.
34 c::::=JI certify that the health care provideris a non-profit or public entity.
35 c::::=JI certify that the health care provider is located in a rural area. Visit the RHCD website: (http://www.usac.org/rhc/tools/rhcdb/Rural/2005/search.asp) or contact RHCD at 1-800-229-5476 for a listing of rural areas.
36 c::::=JPursuant to 47 C.F.R. Sees. 54.601 and 54.603. I certify that the HCP or consortium that I am representinq satisfies all of the requirements herein and will abide by all of the relevant requirements. includinq all applicable FCC rules. with respect to fundinq provided under 47 U.S.C. Sec. 254.
37 Signature		38 Date
39 Printed name of authorized person		40 Title or position of authorized person
41 Employer of authorized person		42 Employer's FCC RN
Please remember: • Form 465 is the first step a health care provider must take in order to receive the benefit of reduced rates resulting from participation in this universal service support program. • After the HCP submits a complete and accurate Form 465, the RHCD will post it on the RHCD web site for 28 days. • HCPs may not enter into agreements to purchase eligible services from service providers before the 28 days expire. • After the HCP selects a service provider, the HCP must initiate the next step in the application process, the filing of Form 466 and/or 466A.

Persons wrllfully makrng false statements on thrs form can be punrshed by fine or forferture under the Communrcatrons Act, 47 U.S.C. Sees. 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 purpose of the information is to determine your eligibility for certification as a health care provider. 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

30 Lanidex Plaza West, P.O.Box 685

Parsippany NJ 07054-0685

FCC Form 465

November 2012