FCC Form 462 Healthcare Conect Fund Funding Request Form

FCC Form 462

Subject to Approval by OMB 3060-0804
Estimated time per response: 2 hours

Rural Health Care (RHC) Universal Service
Healthcare Connect Fund
Funding Request Form
Read instructions thoroughly before completing this form. Failure to comply may cause delayed or denied funding.
Block 1: General Information
1 Funding Year ___________

2 Funding Request Number (FRN):

3 HCP Number:

4 Site Name/Consortium Name:

Block 2: Competitive Bidding Information
5 FCC Form 461 Application Number:
6 Allowable Contract Selection Date (ACSD):
7 Number of vendors who bid:
8 Request for competitive bidding exemption (Only complete if claiming a competitive bidding exemption).
Annual Undiscounted Cost of $10,000 or less
Government Master Services Agreement

Contract ID:

Friendly Name:

Pre-Approved Master Services Agreement

Contract ID:

Friendly Name:

Evergreen Contract

Contract ID:

Friendly Name:

E-Rate Approved Contract

Contract ID:

Friendly Name:

Block 3: Vendor Information
9 Service provider identification number (SPIN):
10 Vendor name:
Block 4: Type of Funding Request
11

Individual HCP, single eligible expense
Individual HCP, multiple eligible expenses
Consortium Application

Block 5: Single Eligible Expense Request for Funding
12 Category of Expense

13 Expense Type

14 Bandwidth

14a Is this service symmetrical?
Yes
No
If no, what is the upload bandwidth ___________.
What is the download bandwidth ___________.

15 Circuit ID (optional)
16 Percentage of expense eligible

17 Does the Service Type include both eligible and ineligible components?

Yes

No

If yes, percentage of usage eligible ___________________
18 Billing Account Number (BAN)
19 Contract ID

19a Date contract signed

19b Expected service start date

19c Length of initial contract term

19d Number of contract extensions

19e Length of optional extension(s) combined

20 Circuit start location

21 Circuit end location

22 Is this a multi-year funding request?

Yes

No

Multi-year commitments cannot exceed 3 funding years and may not
extend beyond the expiration date of an Evergreen Contract.

23 Expense frequency

24 Quantity of expense periods

25 Undiscounted cost per expense period

26 Source of HCP contribution

27 One-time installation charges

FCC Form 462

Block 1: General Information
28 This contract contains a Service Level Agreement.
If yes, provide the following information
concerning the SLA in the contract:

Yes

No

a. Latency:

b. Jitter:

c. Packet Loss:

d. Reliability:

Block 6: Multiple Eligible Expenses and Consortium Requests for Funding (attach Network Cost Worksheet)
29 Total undiscounted cost for eligible recurring expenses
30 Total undiscounted cost for eligible non-recurring expenses
Block 7: Additional Documentation
31 List all supporting documentation (Competitive bids, Contract, etc.) that is required to be submitted with this form.
Type of Documentation
a.
b.
c.
Block 8: Request for Confidentiality
32 Is applicant requesting confidential treatment and non-disclosure of commercial and financial information? (See
instructions for specific information covered by this request.)
Yes
No
Block 9: Certifications
33

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

34

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.

35

I certify under penalty of perjury that the health care provider or consortium has considered all bids
received and selected the most cost-effective method of providing the requested services. The “most costeffective service” is defined as the “method that costs the least after consideration of the features, quality of
transmission, reliability, and other factors that the health care provider deems relevant to choosing a method
of providing the required health care services.” 47 C.F.R. Sec. 54.642(c).

36

I certify under penalty of perjury that all Healthcare Connect Fund support will be used only for the eligible
program purposes for which support is intended.

37

I certify that the health care provider or consortium is not requesting support for the same service from both
the Telecommunications Program and the Healthcare Connect Fund.

38

I certify that the health care provider or consortium satisfies all of the requirements under Section 254 of the
Telecommunications Act of 1996, as amended, and applicable Commission rules, and understand that any
letter from the Administrator that erroneously commits funds for the benefit of the applicant may be subject to
recission.

39

I certify that I have reviewed all applicable requirements for the program and will comply with those
requirements.

40

I understand that all documentation associated with this application, including all bids, contracts, scoring
matrices, and other information associated with the competitive bidding process, and all billing records for
services received, 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.

41 Signature

42 Date

43 Printed Name of Authorized Person
44 Title/Position of Authorized Person
45 Phone
47 Employer

Ext.

46 Email
48 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

Subject to Approval by OMB 3060-0804
Estimated time per response: 2 hours

FCC Form 462

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 2 hours 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: 2 hours

FCC Form 462

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Contract Information
E
F
G
J

Reliability

Packet Loss

Jitter

P

Latency

Eligible Expense Information
K
L
M
N O

Service Level
Agreement

Download Speed
Expected
Broadband
Service Start
date/Shipping
Date/Last Day of
Work

Upload Speed

Is this Service
Symmetrical?

Explanation of
Eligible Expense

Expense Type

I

Category of
Expense

H
Billing Account
Number

Length of optional
extension(s)
combined

Number of
contract extensions

Length of initial
contract term

D

Date Contract
Signed/Vendor
Selected

Site
Information
A
B
C

Contract Friendly
Name

Contract ID

Site Name

HCP Number

Line Number

Rural Health Care (RHC) Universal Service
Healthcare Connect Fund
Network Cost Worksheet (attach, if required, to Form 462)
Subject to Approval by OMB 3060‐0804
Estimed time per response: 5 hours

Quality of Service
Guarantees (if
applicable and
available)
Q
R S T U

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
AB
AC

Expense
Frequency

AH
AI

Source of HCP
Contribution

Financial Information
AD
AE
AF
AG
Total Eligible
Undiscounted Cost

Percentage of
Usage Eligible

Percentage of
Expense Eligible

Undiscounted
Cost per Item, per
Expense Period

Quantity of
Expense Periods

AA
Multi-Year Funding
Request

Circuit Information (if applicable)
W
X
Y
Z
Quantity of Items

Number of Fiber
Strands Eligible for
Support (If
applicalbe)

Total Number of
Fiber Strands (if
applicable)

V

Circuit Start
Location (if
applicable)
Circuit End
Location (if
applicable)

Circuit ID (if
available)

Line Number (continued)

Rural Health Care (RHC) Universal Service
Healthcare Connect Fund
Network Cost Worksheet (attach, if required, to Form 462)
Subject to Approval by OMB 3060‐0804
Estimed time per response: 5 hours