Universal Service - Rural Health Care Program

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RHC PILOT PROGRAM – TRANSFER OF LETTER OF AGENCY TEMPLATE

ASSIGNMENT OF LETTER OF AGENCY TO THE CALIFORNIA TELEHEALTH NETWORK

In 2008, [Name of Healthcare Provider] signed a Letter of Agency authorizing the Regents of the University of California (“Regents”) to acts on its behalf before the Federal Communications Commission in matters related to its participation in the California Telehealth Network. Since that time, the California Telehealth Network has been incorporated as a 501(c)(3). The Regents and the California Telehealth Network have worked together to transfer the Regent’s responsibilities as the Lead Entity in the Rural Health Care Pilot Program project to the California Telehealth Network.

By this letter, [Name of Healthcare Provider] transfers the authorizations outlined in the Letter of Agency to the California Telehealth Network and its successors or assigns. This authorization is effective until the network build-out deadline as defined by the FCC.¹

[Name of Health Care Provider]

Member of the California Telehealth Network

Signature: _____________________________ Date: ___________

Name:

Title of Authorized Person:

Address:

Phone Number:

Email Address:

1 See In the Matter of Rural Health Care Support Mechanism, WC Docket 02-60, Order, 22 FCC Rcd 20360, ¶¶ 35, 94 (2007) (defining the network build-out deadline as five years from the Pilot Program Participant’s receipt of the initial Funding Commitment Letter. ).