Universal Service - Rural Health Care Program

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RHC PILOT PROGRAM – LETTER OF AGENCY TEMPLATE

[[HEALTH CARE PROVIDER’S LETTERHEAD]]

[[Addressed To Rural Health Care Pilot Program Participant’s Lead Project Coordinator]]

Re: Letter of Agency for Rural Health Care Pilot Program

By this letter, [Health Care Provider Name] confirms its participation in the [Name of Pilot Program Participant]’s Rural Health Care Pilot Program. [Health Care Provider Name] hereby authorizes [Pilot Program Participant Name] to act on its behalf before the Federal Communications Commission (FCC) in matters related to the Rural Health Care Pilot Program. [Health Care Provider Name] is a [member of /participant in] the [Pilot Program Participant]’s [alliance/consortium/network etc.]. [Health Care Provider Name] authorizes [Pilot Program Participant Name] to submit FCC Form 465, FCC Form 466-A, FCC Form 467 and any other Rural Health Care Pilot Program forms and attachments to the Rural Health Care Division of the Universal Service Administrative Company on behalf of [Health Care Provider Name]. This Letter of Agency is effective from the date of this letter to the network build-out deadline as defined by the FCC.¹

By this Letter of Agency, [Health Care Provider Name] authorizes [Pilot Program Participant Name] to make the certifications included in the FCC Forms 465, 466-A and 467 on behalf of [Health Care Provider Name]. In addition to the certifications contained in the above referenced FCC Forms, [Health Care Provider Name] certifies to the following:

1. [Health Care Provider Name] certifies that it is a non-profit or public entity.

2. [Health Care Provider Name] certifies that it has followed any applicable State or local procurement rules.

3. [Health Care Provider Name] certifies that telecommunications services and network capacity provided to it as a result of its participation in the Pilot Program will be used solely for purposes reasonably related to the provision of health care service or instruction that it 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.

4. [Health Care Provider Name] certifies that it will retain documentation of its purchases of service related to the Pilot Program for five years from the end of the funding year.

5. [Health Care Provider Name] acknowledges that FCC rules provide that individual health care facilities participating in the Pilot Program that have been convicted of a felony, indicted, suspended, or debarred from award of federal or state contracts or are not in compliance with the FCC’s rules and regulations, are not be eligible for discounts under the Pilot Program.

6. [Health Care Provider Name] certifies that, to the best of its knowledge, the non-discount portion of the costs for eligible services will not be paid by the service provider.

7. [Health Care Provider Name] acknowledges that the provision, by the provider of a supported service, of free services or products unrelated to the supported service or product constitutes a rebate of some or all of the cost of the supported services.

8. [Health Care Provider Name] certifies that [name of person authorized to sign LOA] is authorized to sign this Letter of Agency and is authorized to act on behalf of [Health Care Provider Name] in matters related to the Pilot Program. [Authorized Person]’s contact information is provided below.

9. [Health Care Provider Name] acknowledges that it shall be subject to audit by the FCC and, if necessary, investigated by the FCC, to determine compliance with the Pilot Program, FCC rules and orders as well as section 254 of the Communications Act of 1934, as amended.

[Name of Health Care Provider]

[Description of Relationship to Pilot Program Participant, e.g. Member of [Name’s Rural Healthcare Network Consortium]]

Signature _________________________

Name

Title of Authorized Person

Address

Phone Number

Email Address

Date

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. ).

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