Form FCC 460 FCC 460 RHCP Description of Eligibility and Registration

Rural Health Care
Healthcare Connect Fund Program
Description of Eligibility and Registration FCC Form 460
(Note: This is a representative description of the information to be collected via the online portal and is not intended to be a visual
representation of what each applicant will see, the order in which they will see information, or the exact wording or directions used to collect
the information. Where possible, information already provided by applicants from previous filing years or that was pre-filed in the system portal
will be carried forward and auto-populated into the form.)
Item #
1

Field Description
Applicant’s FCC Form Nickname

Category
Request Information

2

FCC Form 460 Application Number

System Generated

3
4

Site Name
Legal Entity Name

Site Information
Site Information

5

Site Information

7

Legal Entity FCC Registration
Number
Employer Identification Number
(EIN)
Site Number

8

National Provider Identifier (NPI)

Site Information

9

Organization Taxonomy Code

Site Information

10

Site Taxonomy Code

Site Information

6

Purpose/Instructions
To create a unique identifier for this request, the user simply enters a
nickname (e.g., 2016 Funding Year Homewood FCC Form 460).
Auto-generated by the system: This is a USAC-assigned unique identifier
for this request. This number is automatically created when a user
creates an FCC Form 460.
This is the name of the organization submitting this request.
This is the name of the Legal Entity that owns and/or operates the site. In
some cases, the Legal Entity Name will be different from the Entity or
Consortium Name.
This is the unique FCC identifier for the Legal Entity that owns and/or
operates the site.
The EIN is also known as a Federal Tax Identification Number, and is used
to identify a business or non-profit entity.
Auto-generated by the system: This is the unique identifier assigned by
the Universal Service Administrative Company (USAC) to the site listed in
Site Name. This number is automatically created when a user creates an
FCC Form 460.
This is the ten-digit health care facility NPI used on Medicare and
Medicaid claims.
This is the ten-digit Healthcare Provider Taxonomy Code that
corresponds to the NPI.
Optional. Should the Organization Taxonomy Code not adequately
describe the site, the user may add additional Taxonomy Codes.

Site Information
System Generated

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Item #
11

Field Description
Site Address

Category
Site Information

12
13

Site Website
Type of Registration

Site Information
Site Information

14

Type of Registration: If Data Center

Site Information

15

Type of Registration: If
Administrative Center
Eligibility Entity Type that Seeks
Support

Site Information

Eligibility Entity Type that Seeks
Support: If Rural Health Clinic
Eligibility Entity Type that Seeks
Support: If Non-Profit Hospital
Eligibility Entity Type that Seeks
Support: If Non-Profit Hospital
Eligibility Entity Type that Seeks
Support: If Community Mental
Health Center
Eligibility Entity Type that Seeks
Support: Additional Site
Information

Site Information

16

17
18
19
20

21

Purpose/Instructions
This is the site’s physical address, county, city, state, zip code and
geolocation. Geolocation only applies to a site that does not have a
street address.
Optional. The website address of the site.
This is the selection of the applicant as a health care provider (HCP) site,
Consortium, Off-site data center, Off-site administrative office or
Ineligible site.
A list of all sites (eligible and ineligible) that will use the services of the
data center.
A list of all sites (eligible and ineligible) that will use the services of the
administrative center.
These are the eligible health care provider categories as provided in 47
C.F.R. §54.600(a): Community health center or health center providing
health care to migrants; community mental health center; local health
department/agency; non-profit hospital; part-time eligible entity located
in an ineligible facility; post-secondary educational institution offering
health care instruction; teaching hospital or medical school; rural health
clinic; dedicated emergency room (ER) of rural, for-profit hospital; skilled
nursing facility; consortium of the above.
If the user chooses “Rural Health Clinic,” the user selects whether or not
the site is a mobile rural HCP.
If the user chooses “Non-Profit Hospital,” then the user indicates if the
hospital is a Critical Access Hospital.
If the user chooses “Non-Profit Hospital,” then the user will be asked to
define how many licensed patient beds are on site.
If the user chooses “Community Mental Health Center,” then the user
must submit the Community Mental Health Center Checklist and a copy
of the HCP’s operating license.
If applicable, the user indicates if the site is located on Tribal lands,
operated by the Indian Health Service, and/or otherwise affiliated with a
Tribe.

Site Information

Site Information
Site Information
Site Information

Site Information

2

Item #
22

Field Description
Eligibility Entity Type that Seeks
Support: Additional Site
Information
Consortium Name
Consortium Number

Category
Site Information

Purpose/Instructions
Optional. The user has the ability to provide a brief explanation of why
the site qualifies as the eligibility category selected.

Consortium Details
System Generated
Consortium Details
Consortium Details

This is the unique FCC identifier for the consortium.

27

Consortium: Legal Entity
Identification
Consortium FCC Registration
Number
Consortium Leader Name

The name of the consortium.
The unique identifier assigned by USAC to the consortium listed in
Consortium Name.
The user indicates if the consortium is a Legal Entity.

Consortium Details

28

Consortium Leader Type

Consortium Details

29

Consortium Leader: If Eligible
Healthcare Provider Member
Written Agreement Allocating Legal
and Financial Responsibility

Consortium Details

Written Agreement Allocating Legal
and Financial Responsibility: Yes
Exemption for State/Non-Profit
Entities Serving as Both Vendor and
Consortium Leader/Consultant

Consortium Details

This is the organization that will serve as the main point of contact for
USAC and the FCC, and who will act on behalf of the consortium
members.
The user identifies the consortium as either: an eligible Healthcare
Provider member of the consortium, State organization, Public sector
(government) entity, Non-Profit entity, or Consortium itself if organized
as a Legal Entity. A state organization, public sector entity, or non-profit
entity may obtain an exemption to allow the organization to perform
vendor functions and provide application assistance.
If the user selects “Eligible healthcare provider member of the
consortium,” then they provide a site number for their site.
The user indicates if the consortium has a written agreement allocating
legal and financial responsibility. By default, the consortium leader is the
legally and financially responsible entity for the conduct of activities
supported by the universal service fund.
User uploads Written Agreement Allocating Legal and Financial
Responsibility document.
For consortia only. An entity seeking to obtain an exemption from not
being able to serve as both the vendor and the consortium
leader/consultant, must make a showing to USAC that they have set up
an organizational and functional separation. This exemption must be
obtained before preparing the FCC Form 461 and associated documents.

23
24
25
26

30

31
32

Consortium Details

Consortium Details

3

Item #
33

Field Description
Exemption for State/Non-Profit
Entities Serving as Both Vendor and
Consortium Leader/Consultant: Yes
Consortium Leader Address
Consortium Website
Primary Account Holder Contact
Name

Category

Purpose/Instructions
User provides written documentation showing that they have set up an
organizational and functional separation.

Consortium Details
Consortium Details
Contact Information

37

Primary Contact Employer

Contact Information

38

Primary Contact Mailing Address

Contact Information

39

Contact Information

40

Primary Contact Telephone
Number
Primary Contact Email Address

41

Legal Entity Website

Contact Information

42

Additional Contact(s)

Contact Information

This is the consortium mailing address, county, city, state, and zip code.
Optional. The website address of the consortium.
This is the name of the person who should be contacted with questions
about this request. The Consortium Leader or Entity must designate a
Primary Contact for purposes of interacting with USAC. This person must
be employed by the Legal Entity listed on this FCC Form. The Primary
Contact has the ability to view, create, and enter data in the forms, and
electronically certify, sign and submit forms, on behalf of the Entity or
Consortium.
This will auto-populate to be the information listed within “Legal Entity
Name” (Item # 4).
This is the mailing address, county, city, state, and zip code of the person
who should be contacted with questions about this request.
This is telephone number of the person who should be contacted with
questions about this request.
This is the email address of the person who should be contacted with
questions about this request.
Optional. The website address of the Legal Entity that owns and/or
operates the Entity or Consortium. Explains more about what the Legal
Entity is in relation to a site and consortium. This is the website for the
organization listed in Item #4.
Optional. Allows the user to add additional contact person(s) to the
request. Additional contacts will have access to forms and have the
ability to answer specific questions about the applications associated
with a funding request. They also have the ability to sign, certify and
submit forms on behalf of the applicant. To add an additional contact
person, the user must provide the contact’s name, employer, mailing
address, county, city, state, zip code, telephone number, email address
and website.

34
35
36

Contact Information

4

Item #
43
44

45

46

47

48

Field Description
Supporting Documentation

Category
Documentation

I certify that I am authorized to
submit this request on behalf of the
site or consortium.
I declare under penalty of perjury
that I have examined this request
and attachments and to the best of
my knowledge, information, and
belief, all information contained in
this request, and in any
attachments, is true and correct.
I understand that all
documentation associated with this
request 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.
If applying as an individual
Healthcare Provider site, I certify
that the Healthcare Provider is
either a non-profit, public entity or
a dedicated ER of a rural for-profit
hospital.
If applying as an individual
Healthcare Provider site, I certify
that the site is located in a FCC
designated rural area, or is a
grandfathered rural pursuant to 47
C.F.R. § 54.600(b)(2).

Certifications

Purpose/Instructions
Optional. Provides an option for the user to upload and submit
documents to support their request.
The Authorized Person is required to make all required certifications and
signatures.

Certifications

See Item #44, Purpose/Instructions above.

Certifications

See Item #44, Purpose/Instructions above.

Certifications

See Item #44, Purpose/Instructions above. Only applies to those
applying as an individual Healthcare Provider site.

Certifications

See Item #44, Purpose/Instructions above. Only applies to those
applying as an individual Healthcare Provider site.

5

Item #
49

Category
Certifications

Purpose/Instructions
See Item #44, Purpose/Instructions above. Only applies to those
applying as a consortium.

Certifications

See Item #44, Purpose/Instructions above. Only applies to those
applying as a consortium.

51

Field Description
If applying as a consortium, I certify
that the eligible Healthcare
Providers participating in the
consortium are either non-profit or
public entities or dedicated ER(s) of
a rural for-profit hospital.
If applying as a consortium, I
understand I must obtain letters of
agency from each consortium
member that grants me the
authority to complete, sign, and
submit all requests for the funding
year(s) for which support is sought.
Signature

Signature

52

Date Submitted

System Generated

53

Date Signed

System Generated

54

Authorized Person

Signature

55

Authorized Person’s Employer

Signature

56

Authorized Person’s Employer FCC
Registration Number

Signature

The Authorized Person is required to make all required certifications and
signatures. The request must be certified electronically.
Auto generated by system: This date is assigned based on the date the
user submits the FCC Form 460.
Auto generated by system: This date is assigned based on the date the
user signs the FCC Form 460.
This is the name of the Authorized Person (either the Primary Contact or
an Additional Contact) that is signing the FCC Form.
Auto-generated by the system: Based on either previous information
entered in this FCC Form 460 or based on the details of the logged in
user. This is the name of the employer of the Authorized Person signing
the FCC Form.
Auto-generated by the system: Based on either previous information
entered in this FCC Form 460 or based on the details of the logged in
user. This is the FCC Registration Number of the Authorized Person
signing the FCC Form. This number may be the FCC RN of the Legal
Entity, Consortium or Site.

50

6

Item #
57

Field Description
Authorized Person’s Title/Position

Category
Signature

58

Authorized Person’s Mailing
Address

Signature

59

Authorized Person Telephone
Number

Signature

60

Authorized Person Email Address

Signature

61

Third Party Authorization (TPA)

Request Information

62

Letter of Agency (LOA)

Consortium Details

63

Letter of Exemption (LOE)

Consortium Details

Purpose/Instructions
Auto-generated by the system: Based on either previous information
entered in this FCC Form 460 or based on the details of the logged in
user. This is the title or position of the Authorized Person signing the FCC
Form.
Auto-generated by the system: Based on either previous information
entered in this FCC Form 460 or based on the details of the logged in
user. This is the address (can be physical address or mailing address) of
the Authorized Person signing the FCC Form.
Auto-generated by the system: Based on either previous information
entered in this FCC Form 460 or based on the details of the logged in
user. This is the telephone number of the Authorized Person signing the
FCC Form.
Auto-generated by the system: Based on either previous information
entered in this FCC Form 460 or based on the details of the logged in
user. This is the email address of the Authorized Person signing the FCC
Form.
If applicable, the user must provide a TPA providing written authorization
to a third party/consultant to complete and submit the FCC Form on
behalf of the Healthcare Provider or consortium.
For Consortia only. If applicable, the user must provide an LOA providing
written authorization to the Primary or Additional Contact(s) of a
consortium to act on behalf of each participating Healthcare Provider or
health system not owned or operated by the consortium or organization
operating the consortium.
For Consortia only. If applicable, the user must provide an LOE providing
written authorization to the Primary or Additional Contact(s) of a
consortium to submit requests for sites owned and operated by the
consortium.

7