FCC Form 461 Healthcare Connect Fund Request for Services Form

FCC Form 461

Subject to Approval by OMB 3060-0804
Estimated time per response: 1 hour

Rural Health Care (RHC) Universal Service
Healthcare Connect Fund
Request for Services Form
USAC Internal Use Only
FCC Form 461 Application Number:

FCC Form 460 Number:

Posting Start Date:

Posting End Date:

Allowable Contract Selection Date (ACSD):

Form 461 Friendly Name:

Read instructions thoroughly before completing this form. Failure to comply may cause delayed or denied funding.
Block 1: General Information
1 Funding Year

2 HCP Number

3 Site Name/Consortium Name
4 Address Line 1
5 Address Line 2

6 County

7 City
Block 2: Individual HCP Site Request for Services
10

8 State

9 Zip Code

Applicant has prepared and is submitting an RFP with this form.
Applicant has not and will not prepare an RFP.

10a Requested contract period
10b Expected bid evaluation period
11 Number of Days Posted
Number of days USAC should post: ______________

Posting end date: ______________

12 Category of Expense Requested (check all applicable):
Network Equipment
Leased/Tariffed Facilities or Services

12a Identify Anticipated Application(s) and Use(s) of the Supported Connection
The Fund only provides support for costs associated with broadband connectivity. The additional expenses
associated with specific applications (e.g., exchange of electronic health records) are not eligible for support under
the Healthcare Connect Fund.
(Select all that apply. Describe usage level and usage period for all selected.)
Capability
Category: Interactive
Distance learning/training
Real-time remote examination, consultation,
and/or monitoring
Video conferencing
Voice service
Other (describe): _____________
Category: Transactional
Distance learning/training
Electronic patient billing
Exchange of electronic health records
Internet access

Usage Level

Usage Period

Transmission of large files (e.g., X-ray
images, MRI, etc.)
Other (describe): _____________
Category: Bulk
Electronic patient billing
Exchange of electronic health records
Transmission of large files (e.g., X-ray
images, MRI, etc.)
Transmission of store and forward
consultations
Other (describe): _____________
Category: Miscellaneous
Backup/redundant connectivity
Other (describe): _____________
12b Applicant requesting services for an off-site data center:
Yes

No

If yes, provide HCP Number:

12c Applicant requesting services for an off-site administrative office:
Yes
13

No

If yes, provide HCP Number:

Contact for Request for Services:
Same as HCP Physical Location Contact

Same as HCP Primary Account Holder

Other

13a If other, provide full contact information:
Contact Name

Organization Name

Contact Name Title
Phone
Ext.
Block 3: Consortium Request for Services

Email

14 Participating Entities (list all sites, eligible and ineligible, participating in this request for services):
HCP Number:
HCP Number:

HCP Number:
HCP Number:

15 Indicate whether the Consortium plans to utilize an RFP:
Applicant has prepared and is submitting an RFP with this form. If selected, complete 15a.
Applicant has not and will not prepare an RFP.
15a Applicant is submitting an RFP because:
It is seeking more than $100,000 in program support
It is seeking support for infrastructure

Of state, Tribal, or local procurement rules
The applicant has elected to use an RFP

15b Requested contract period
15c Expected bid evaluation period
16 Number of Days Posted:
Number of days USAC should post: ______________

Posting end date: ______________

17 Category of Expense Requested:
Network Design
Network Equipment
Infrastructure/Outside Plant

Leased/Tariffed Facilities or Services
Network Management/Maintenance/Operations Cost (not captured
elsewhere)

17a If requesting only Infrastructure/Outside Plant, enter FCC Form 461 Application Number in which the Consortium
previously requested Leased/Tariffed Facilities or Services.
FCC Form 461 Application Number:
I certify that the prior FCC Form 461 resulted in no responsive bids.

Subject to Approval by OMB 3060-0804
Estimated time per response: 1 hour

FCC Form 461

18 Description of Services Requested (Required to provide a summary of RFP if submitting one):

19

Contact for Request for Services:
Same as Project Coordinator

Same as Assistant Project Coordinator

Other

19a If other, provide full contact information:
Contact Name

Organization Name

Contact Name Title
Phone
Ext.
Block 4: Declaration of Assistance

Email

20 Have any consultants, service providers, or any other outside experts, whether paid or unpaid, aided in the
preparation of the FCC Forms 460 or 461, RFP, bid evaluation, or network plan?
Yes

No

21 List the contact information for all consultants, service providers, and outside experts that assisted in preparing any
part of the FCC Forms 460, 461, RFP, bid evaluation, or network plan.
a. Name (First, Middle Initial, Last)

b. Organization Type

c. Title/Role

d. Employer

e. Address Line 1
f. Address Line 2
g. City

h. State

i. Zip Code

Block 5: Bid Evaluation
22 Select selection criteria (and weights assigned to each) that will be used to evaluate bids received as a result of this
request for services. Attach supplemental information (if necessary).
Criteria

Weight

a.
b.
c.
Block 6: Additional Documentation
23 List all supporting documentation (RFP, Network Plan, etc) that is required to be submitted with this form.
Type of Documentation
a.
b.
c.
Block 7: Certifications
24

I certify under penalty of perjury that I am authorized to submit this request on behalf of the health care
provider or consortium.

25

I declare under penalty of perjury that I have examined this form and attachments and to the best of my
knowledge, information, and belief, all information contained in this form and in any attachments is true and
correct.

26

I certify under penalty of perjury that the applicant has followed any applicable state, Tribal, or local
procurement rules.

27

I certify under penalty of perjury that the supported connection(s) and network equipment will be used solely
for purposes reasonably related to the provision of healthcare service or instruction that the health care
provider is legally authorized to provide under the law of the state in which the connections are provided. In
addition, I certify under penalty of perjury that the supported connection(s) and network equipment will not
be sold, resold, or transferred in consideration for money or any other thing of value.

Subject to Approval by OMB 3060-0804
Estimated time per response: 1 hour

FCC Form 461

Block 7: Certifications
28

I certify under penalty of perjury that the applicant satisfies all of the requirements under section 254 of the
Communications Act, 47 U.S.C. § 254, and applicable Commission rules.

29

I certify under penalty of perjury that the applicant has reviewed all applicable requirements for the program
and will comply with those requirements.

30

I understand that all documentation associated with this form, including a copy of the signed 461, any bids/
contracts resulting from the 461 posting, scoring sheet, and other information that was used in the decision
making process, must be retained for a period of at least five years pursuant to 47 C.F.R. § 54.648, or as
otherwise prescribed by the Commission’s rules.

31 Signature

32 Date

33 Printed Name of Authorized Person
34 Title/Position of Authorized Person
35 Phone

Ext.

37 Employer

36 Email
38 Employer’s FCC RN

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.

Subject to Approval by OMB 3060-0804
Estimated time per response: 1 hour

FCC Form 461