Universal Service - Rural Health Care Program

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3060—0804
Estimated time per response: 1 hour
November 2011

Form 465 Instructions
Rural Health Care Universal Service Mechanism

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PURPOSE OF FORM
FCC Form 465 is the first step a health care provider (HCP) must take in order to benefit from the
universal service support mechanism. Universal service support allows eligible health care providers to
purchase certain services at reduced rates. Form 465 is the means by which a health care provider:
1. Requests bids for the provision of telecommunications or Internet services from service providers.
2. Certifies to the Rural Health Care Division of the Universal Service Administrative Company, which
serves as the administrator, that the health care provider is eligible to benefit from the universal
service support mechanism.
Health care providers who have previously posted a Form 465 can register for electronic certification.
Electronic certification allows the health care provider to electronically sign the new Form 465 so it can be
immediately posted on the RHCD website, www.usac.org/rhc/.
After the health care provider submits a Form 465, the Rural Health Care Division (RHCD) will post the
completed Form 465 on its website. The posted Form 465 provides information about the HCP and its
need for services to service providers that might wish to bid to provide the services.
Each health care provider’s Form 465 must be posted on the RHCD website for at least 28 days prior to
selecting a service provider, to fulfill the program’s competitive bidding requirement.
Rural health care providers may enter into agreements to purchase services after 28 days have
elapsed since the descriptions set forth in Form 465 were posted on the RHCD website. Entering
into any agreement during the 28-day posting period is prohibited.
RHCD will send each applicant a “Receipt Acknowledgement Letter” confirming that its Form 465 is
posted on the website. The confirmation of posting sent by RHCD will indicate the date on which the
health care provider may enter into an agreement to purchase services from a service provider. This date
is known as the Allowable Contract Selection Date (ACSD).
The health care provider must certify to RHCD that the service chosen is, to the best of the health care
provider's knowledge, the most cost-effective service. "The most cost-effective service" is defined in the
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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 relevant to
choosing an adequate method of providing the required health care services.” This requirement is
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reiterated for Internet service in the Rural Health Care Order.

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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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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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Rural Health Care Support Mechanism, WC Docket No. 02-60, Report and Order, Order on Reconsideration,
and Further Notice of Proposed Rulemaking, 18 FCC Rcd 24546 (2003) (2003 Report and Order and FNPRM).

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After the HCP enters into a service agreement, it must initiate the next step in the application process, the
filing of an FCC Form 466 (Funding Request and Certification Form) and/or 466-A (Internet Service
Funding Request and Certification Form and Advanced Services Funding Request and Certification for
Entirely Rural States).
FILING REQUIREMENTS AND GENERAL INSTRUCTIONS
Who is Eligible
An HCP must meet two criteria in order to benefit from the universal service support mechanism.
First, it must be a public or non-profit health care provider that falls within one of the following categories:
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Post-secondary educational institution offering health care instruction (including teaching hospitals
and medical schools);
Community health center or health center providing health care to migrants;
Local health department or agency;
Community mental health center;
Not-for-profit hospital;
Rural health clinic;
Consortium of health care providers consisting of one or more of the above entities;
Dedicated emergency department of for-profit hospitals, including Critical Access Hospitals;
Part-time eligible entity.

Health care providers that do not fall into one of these categories are not eligible to benefit from the
universal service support mechanism.
Second, a health care provider must be located in a rural area to qualify for support. An HCP can
determine if it is in an area that meets the Federal Communication Commission's definition of "rural" by
consulting the RHCD website at www.usac.org/rhc/tools/rhcdb/Rural/2005/search.asp, or by calling the
Rural Health Care Division at 1-800-229-5476 for assistance. HCPs that meet both the eligible category
and rural criteria are considered "eligible health care providers”. (There is a limited exception to the rural
requirement for urban HCPs that must pay toll charges to reach the Internet. Such urban HCPs may
receive the lesser of $180 or 30 hours for toll charges to reach the Internet. This is the only exception to
the requirement that an HCP must be rural to benefit from the universal service support mechanism.)
Filing Exception - The filing of a Form 465 may not be required if the HCP is receiving services under a
currently valid contract executed pursuant to a Form 465 posted in a prior program year, or if services are
received under a contract signed on or before July 10, 1997. A renewed contract or a contract with an
automatic renewal provision is considered a new contract on the renewal date, and an expired contract is
not considered a currently valid contract. Questions about the status of an HCP’s contract may be
directed to RHCD at 1-800-229-5476. Applicants who are not required to file a Form 465 must still
file a Form 466 and/or 466-A for each program year to receive support for the contracted services.
Where to File
The FCC Form 465 must be filed with the Rural Health Care Division at:
Rural Health Care Division
30 Lanidex Plaza West, P.O.Box 685
Parsippany, NJ 07054-0685
The health care provider may also file this form electronically. Instructions on how to file electronically are
posted on the RHCD website at www.usac.org/rhc/. DO NOT FILE THIS OR ANY OTHER UNIVERSAL
SERVICE FORM WITH THE FEDERAL COMMUNICATIONS COMMISSION.

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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 the Rural Health Care Division at 1-800-229-5476 for more information on how to complete this or
other universal service forms. Information is also available on the RHCD website at www.usac.org/rhc/.
SPECIFIC INSTRUCTIONS FOR FILING FORM 465
Type or print clearly in spaces provided. Attach additional sheets if necessary. Applicants are also
encouraged to complete this form electronically to speed up the processing of applications. RHCD will
post all applications on the RHCD website at www.usac.org/rhc/. Instructions on how to file electronically
are posted on the website.
Form 465 Application Number
The RHCD will insert the Form 465 Application Number (known in prior years as the "Universal Service
Control Number"). Leave this line blank.
Block 1: HCP Location Information
The information required in this block applies to the physical location of the HCP. Do not enter a “PO Box”
or “Rural Route” address.
Line 1 requires providing an HCP number. The HCP number is a unique identifier given by RHCD to
each health care provider applying for benefits from the Universal Service Rural Health Care Support
Mechanism. If an HCP previously applied, RHCD has already assigned a number, which must be used
here. If it is unknown whether the HCP has already been assigned a number, call the Rural Health Care
Division at 1-800-229-5476. If the HCP is a new applicant, leave this line blank. RHCD will assign an
HCP number to each new eligible applicant upon receipt of the Form 465.
Line 2 requires identifying the name of the consortium to which the HCP belongs, if any. (If the HCP does
not belong to a consortium, leave Line 2 blank.)
Line 3 requires providing the health care provider’s organization name. This name must be used
consistently on all universal service forms (i.e., Form 465, Form 466, Form 466-A, & Form 467).
Line 4 requires providing the HCP’s FCC Registration Number (FCC RN). All participants in the Rural
Health Care Program must have an FCC RN in order to participate. Information on how to get an FCC
RN is available on the FCC website at www.fcc.gov.
Line 5 requires providing the name of a contact person at the health care provider’s location.
Lines 6-14 require providing the HCP contact person’s address, county in which the HCP is located, city,
state, zip code, phone, fax, and E-mail address.
Block 2: HCP Mailing Contact Information
Line 15 requires indicating whether or not the HCP’s mailing address is different from the address in
Block 1. If “No” is checked, skip the remainder of Block 2 and proceed to Block 3. The person listed in

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Block 2 will serve as RHCD’s primary contact with the HCP. This person should be able to answer
questions or verify information submitted on this form, in the event that RHCD needs to contact the HCP
during the application process.
Line 16 requires identifying the name of the person to receive mail regarding the Form 465.
Line 17 requires providing the mailing contact person’s organization (which might be the same as the
HCP or consortium name).
Lines 18-25 require providing the address, city, state, zip code, phone, fax, and E-mail address of the
mailing contact.
Block 3: Funding Year Information
Line 26 requires identifying the funding year for which the HCP is applying. The applicant should check
only one box.
Block 4: Eligibility
Line 27 requires checking the box indicating the eligibility category of the HCP. Only public or non-profit
health care providers located in rural areas that fall into one of the categories listed in Line 27 are eligible
to benefit from this universal service support mechanism. Rural for-profit hospital emergency departments
may also qualify as “public” by virtue of their requirement to examine or treat patients pursuant to the
Emergency Medical Treatment and Labor Act (EMTALA).
Note that applicants that apply as a consortium of health care providers may only receive support for
services provided to the physical location given in Block 1, meaning that unless the “above entities” are at
that address, they cannot receive support. Rather, a separate Form 465 should be filed for each eligible
entity in the consortium, using that entity’s address, so it can be verified as rural and its Maximum
Allowable Distance can be determined. Applicants selecting the consortium category must complete Line
28, and may call RHCD at 800-229-5476 for further explanation of their eligibility.
The categories of “Dedicated emergency department of rural for-profit hospitals including Critical Access
Hospitals” and “Part-time eligible entity” were defined in the Rural Health Care Order, and are further
discussed under “Eligibility and Support Percentage for For-Profit Hospital Emergency Department or
Part-Time Rural Health Clinic” on the RHCD website at www.usac.org/rhc/. Applicants that select these
categories should review the website material to determine if they qualify, and to recognize that they may
only be eligible for partial support of their selected service. Applicants selecting these categories must
complete Line 28, and may call RHCD at 800-229-5476 for further questions about eligibility.
Line 28 must be completed if “Consortium of the above”, “Dedicated emergency department of rural forprofit hospitals including Critical Access Hospitals”, or “Part-time eligible entity” was selected in Line 27. A
description of the entity and the services it provides is required.
Line 29 requires a description of how the health care provider will use the supported service. This
description will allow service providers to learn what the health care provider wants to do, so they can
propose services to meet the health care provider’s needs. Some examples are transmission of data and
medical images or X-rays; provider-to-provider consultation between health care professionals in a rural
facility and professionals in other locations, provider-to-patient consultation, examination, or counseling;
medical research, access to the health care provider’s website, offsite storage of medical records, or other
uses.
Block 5: Request for Services
Line 30 requires indicating whether the HCP is requesting support for a telecommunications service,
Internet service, or both. A Form 465 must be posted for the type of service (telecommunications or

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Internet) for which support will be sought, e.g., a Form 465 posted for telecommunications service only
would not be eligible to request support for Internet service. If additional guidance on eligible services
is needed, please contact RHCD at 1-800-229-5476.
Block 6: Certification
Line 31 requires the person signing on behalf of the HCP to certify that he or she is authorized to submit
the information contained in the Form 465 on behalf of the entity or entities (if a consortium) applying for
discounted services, and that the information contained in the Form 465 is true to the best of his or her
knowledge, information and belief. Under federal law, persons willfully making false statements on this
form can be punished by fine, forfeiture, or imprisonment.
Line 32 requires the authorized representative of the HCP to certify that any applicable state or local
procurement rules have been followed.
Line 33 requires the authorized representative to certify that the services for which the health care
provider receives a discount will not be used for unauthorized purposes. Specifically, the representative
must certify that such services will be used solely for purposes reasonably related to the provision of
health care or instruction that the health care provider is legally authorized to provide under the law of the
state in which the services are provided. The representative must also certify that the discounted services
that the HCP receives will not be sold, resold, or transferred in consideration for money or any other thing
of value.
Line 34 requires certifying that the HCP is a non-profit or public entity, or that the service will be used
exclusively in the emergency department of a rural for-profit hospital.
Line 35 requires identifying whether or not the HCP is located in an eligible rural area or if the HCP is a
mobile rural health clinic, that it will operate in eligible rural areas. Visit the RHCD website
www.usac.org/rhc/tools/rhcdb/Rural/2005/search.asp or contact RHCD at 1-800-229-5476 for a list of rural
areas.
Line 36 requires the authorized representative to certify that the HCP satisfies each of the specific
requirements set forth in the Form 465 and that the HCP will abide by the relevant requirements of 47
U.S.C. § 254.
Line 37 requires the signature of the authorized representative certifying the information contained in
Form 465 on behalf of the applicant.
Line 38 requires the date the Form 465 was signed.
Line 39 requires the printed name of the authorized representative certifying the information contained in
Form 465 on behalf of the applicant.
Line 40 requires the title or position of the authorized representative certifying the information contained in
Form 465 on behalf of the applicant.
Line 41 requires the name of the employer of the person signing the Form 465.
Line 42 requires the FCC RN of the employer of the person signing the Form 465.
REMINDERS
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Health care providers seeking to benefit from universal service support must file an FCC Form 465.

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The representative authorized to provide the information required by FCC Form 465 on behalf of a

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health care provider must sign and date FCC Form 465.
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Provide data for all items that apply. Attach additional sheets if necessary. Any attachments to FCC
Form 465 must be clearly labeled.

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.

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