Universal Service - Rural Health Care Program

Approved by OMB
3060—0804
Estimated time per response: .25 hour
November 2011

Form 467 Instructions
Rural Health Care Universal Service Mechanism

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PURPOSE OF FORM
Form 467 is used by a health care provider (HCP) to notify the Rural Health Care Division (RHCD) of the
Universal Service Administrative Company that the service provider began providing the
telecommunications or Internet services for which the HCP is seeking to receive the benefit of reduced
rates through the rural health care universal service support mechanism. It is the last form required in the
application process. This form is also used to notify RHCD when the HCP has discontinued the service
(i.e., service is turned off), or that service was not (or will not be) turned on during the funding year. An
applicant must submit one Form 467 for each Funding Request and Certification Form (Form 466) or
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Internet Service Discount Request (Form 466-A) that it submitted to RHCD.
An HCP will not receive benefits from this universal service support mechanism until RHCD
receives the completed Form 467.
FILING REQUIREMENTS AND GENERAL INSTRUCTIONS
Who Must File
The HCP or its authorized representative must file a Form 467 to certify that the service provider began
providing the service (i.e., the service is turned on), or to notify RHCD that the service provider has ceased
to provide service that the HCP had been receiving at reduced rates as a result of its participation in this
program, or to inform RHCD that service was not (or will not be) turned on during the funding year.
HCPs cannot receive support directly from the Universal Service Fund. Rather, HCPs may receive
the benefit of reduced rates for telecommunications and Internet services from their selected
service providers, who will be compensated for those reduced rates by the Universal Service
Rural Health Care Support Mechanism.
When to File
The HCP or its authorized representative must file Form 467 after it has filed a Form 466 or a Form 466-A
and the service provider(s) has begun to provide the service (i.e., the service is turned on). The HCP or
its authorized representative must also file Form 467 when the service provider has ceased to provide
service that the HCP had been receiving at reduced rates as a result of its participation in this program.
The HCP or its authorized representative must submit a separate Form 467 for each Form 466 or Form
466-A that it previously submitted to RHCD.

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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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FCC Form 466 (Funding Request and Certification Form) and FCC Form 466-A (Internet Service Discount
Request) are the means by which an HCP informs the RHCD that it has entered into an agreement with a service
provider to purchase telecommunications or Internet service.

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Where to File
A paper copy of Form 467 with an original signature or an electronically certified Form 467 must be
submitted for each service requested. (See RHCD website, http://www.universalservice.org/rhc/healthcare-providers/step02/e-certification.aspx, for instructions on Electronic Certification of Form 467).
Applicants are encouraged to complete Form 467 on the RHCD website, but unless the applicant has
been approved for E-Certification, a Form 467 completed on the website MUST BE PRINTED, SIGNED,
and SUBMITTED to the address below.
Rural Health Care Division
30 Lanidex Plaza West, P.O.Box 685
Parsippany, NJ 07054-0685
DO NOT FILE THIS OR ANY OTHER UNIVERSAL SERVICE FORM WITH THE FEDERAL
COMMUNICATIONS COMMISSION.
Compliance
HCPs that fail to file Form 467 will not receive benefits from this universal service support mechanism.
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 website at www.usac.org/rhc/.
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 and match up Form 467 with previous forms that have
been filed on behalf of the HCP.
Line 1 requires providing the HCP’s name. This name must be used consistently on all universal service
forms (i.e., Form 465, 466, 466-A and 467). The HCP name should match the HCP name supplied in
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Line 3 of the Form 465.
Line 2 requires providing the name of the consortium, if the HCP is a member of a consortium. If the
HCP is not a consortium member, Line 2 should be left blank.
Line 3 requires providing the HCP number. The HCP number is a unique identifier given by RHCD to
each HCP applying for benefits. RHCD assigns an HCP number to each new applicant upon receipt of
Form 465. This number is in the funding commitment letter that you received from RHCD, and should
match the HCP number in Line 1 of Form 465.

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Form 465 is the first form that the HCP or its authorized representative filed with RHCD in order to receive
telecommunications or Internet service at reduced rates. All Forms 465 are posted on the RHCD website.

Approved by OMB 3060-0804
Estimated time per response: .25 hour

Block 2: Funding Year Information
Line 4 requires providing 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 of the Form 465
for the same funding year.
Block 3: Action Taken
Block 3 of Form 467 is used to confirm that the HCP is receiving the service for which it is requesting a
discount, and in the event that the service is discontinued, to notify RHCD of the date of disconnection so
that RHCD can arrange for termination of the discount. HCPs must promptly report to RHCD all
connections and disconnections.
Line 5 requires identifying the purpose for which this form is being used. If confirming the connection of a
service, check the first box in Line 5. If notifying RHCD of the disconnection of a service, check the
second box in Line 5 and enter the effective date of the disconnection. If notifying RHCD that the
requested service was never turned on (or will not be turned on) during the funding year, check the third
box in Line 5.
Block 4: Connection Information
For Telecommunications Service - Block 4 requires information about each of the connections that
together comprise the entire circuit for telecommunication service. The telecommunication connection
information in Block 4 (Lines 7, 8, 9, and 10) of Form 467 must match the information provided in Block 4
(Lines 21, 22, 28 and 17) of Form 466. Most circuits only contain one connection (i.e., one
telecommunications carrier provides the entire circuit), in which case only the first column should be
completed. However, some circuits have multiple connections and multiple bills (i.e., more than one
telecommunications carrier) for the same circuit. This form accommodates information for up to four
connections. The information for each connection should be entered in separate columns.
Telecommunications Carrier A must be the carrier that provides the segment of the circuit connecting
directly to the HCP. Telecommunications Carrier B should be the carrier that provides the next segment,
Telecommunications Carrier C the next segment, and Telecommunications Carrier D is the furthest from
the HCP. If the circuit contains more than four connections, please call RHCD at 1-800-229-5476.
For Internet Access Service - Only the first column should be completed. The Internet connection
information in Block 4 (Lines 7, 8 and 9) of Form 467 must match the information provided in Block 4
(Lines 20, 21, and 22) of Form 466-A.
Line 6 requires providing a funding request number. The funding request number is a unique identifier
assigned by RHCD for each discounted service requested by the HCP. This number is in the funding
commitment letter that RHCD previously sent.
Line 7 requires providing the full legal name of each service provider for each connection.
Line 8 requires entering the 9-digit Service Provider Identification Number (SPIN) for the service
provider(s) listed in Line 7. Each service provider should provide its SPIN upon request.
Line 9 requires providing the account number that the service provider has created to bill for the services
provided to the HCP.
Line 10 requires identifying the services and bandwidths for which the HCP is seeking the benefits of
reduced rates. For Internet access enter “Internet”.

Approved by OMB 3060-0804
Estimated time per response: .25 hour

Line 11 requires providing the actual start date for each service.
Line 12 requires the date service was or will be disconnected, if Form 467 is being submitted to notify
RHCD that the discounted service has been terminated. If there are no plans to disconnect the service,
leave this item blank.
Block 5: Certification
Line 13 requires certification that the service(s) identified above have been or are being provided to the
HCP. It also requires certification that the person signing the Form 467 is authorized to submit the
information contained in the Form 467 on behalf of the HCP, and that the information contained in the
Form 467 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 14 requires certification that the HCP satisfies each of the specific requirements set forth in the Form
467 and its instructions, and that the HCP will abide by all relevant requirements of 47 U.S.C. Sec. 254.
Line 15 requires the authorized person to sign his/her name to certify all of the information contained in
Form 467 and all attachments.
Line 16 requires the authorized person to identify the date that the Form 467 was signed.
Line 17 requires the printed name of the authorized person signing Form 467.
Line 18 requires the authorized person signing to identify his/her title or position.
Line 19 requires the name of the organization employing the signer of Form 467.
Line 20 requires the FCC RN of the organization employing the signer of Form 467.
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 verify that the health care provider participating in the universal service support
mechanism has begun to receive, or has stopped receiving, the services for which universal service
support has been allocated. 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 .5 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.

Approved by OMB 3060-0804
Estimated time per response: .25 hour

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.

Approved by OMB 3060-0804
Estimated time per response: .25 hour