FCC Form 465 Description of Services Requested & Certification Form

FCC Form

465

Health Care Providers Universal Service

Approval by OMB

Description of Services Requested & Certification Form

3060—0804
Estimated time per response: 1 hour

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

Form 465 Application Number (assigned by RHCD)
Block 1: HCP Location Information
Information required in this block applies to the physical location of the HCP. Do not enter a "PO Box" or "Rural Route" address.
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
9 City

8 County
10 State

12 Phone #
13 Fax #
Block 2: HCP Mailing Contact Information

14 E-mail

15 Is the HCP’s mailing address (where correspondence should be

Yes, complete Block 2

sent) different from its physical location described in Block 1?
16 Contact Name

11 ZIP Code

No, go to Block 3.
17 Organization

18 Address Line 1
19 Address Line 2
20 City

21 State

22 ZIP Code

23 Phone #
24 Fax #
25 E-mail
Block 3: Funding Year Information
26 Funding Year (Check only one box)
Year 2014 (7/1/2014-6/30/2015)
Year 2015 (7/1/2015-6/30/2016)
x Year 2013 (7/1/2013-6/30/2014)
Block 4: Eligibility
27 Only the following types of HCPs are eligible. Indicate which category describes the applicant. (Check only one.)
Post-secondary educational institution offering health care
Rural health clinic
instruction, teaching hospital or medical school
Community health center or health center providing health
Consortium of the above
care to migrants
Local health department or agency
Dedicated ER of rural, for-profit hospital
Community mental health center
Not-for-profit hospital
Part-time eligible 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:
Both Telecommunications & Internet Services

Telecommunications Service ONLY

Internet Service ONLY
FCC Form 465
November 2012

Block 6: Certification
31
I certify that I am authorized to submit this request on behalf of the above-named entity or entities, that I have examined this request,
and that to the best of my knowledge, information, and belief, all statements of fact contained herein are true.
32

I certify that the health care provider has followed any applicable State or local procurement rules.

33

I certify that the telecommunications services and/or Internet access charges that the HCP receives at reduced rates as a result of the
HCPs' participation in this program, 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 legally
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 thing of value.

34

I certify that the health care provider is a non-profit or public entity.

35

I 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

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 funding
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:
w 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.
w After the HCP submits a complete and accurate Form 465, the RHCD will post it on the RHCD web site for 28 days.
w HCPs may not enter into agreements to purchase eligible services from service providers before the 28 days expire.
w 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 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 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
Approval by OMB 3060-0804
Estimated time per response: 1 hour

FCC Form 465
November 2012