Form 461 RHCP Description of Request for Services

Rural Health Care
Healthcare Connect Fund Program
Description of Request for Services FCC Form 461
(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 # Field Description
1
Applicant’s FCC Form Nickname
2

Funding Year

Category
Request For Proposal
(RFP) Details
RFP Details

3

FCC Form 461 Application Number

System Generated

4

FCC Form 460 Number

System Generated

5

FCC Form 461 Posting Start Date

System Generated

6

FCC Form 461 Posting End Date

System Generated

7

Allowable Contract Selection Date
(ACSD)

System Generated

8

Site Name

System Generated

9

Site Number

System Generated

Purpose/Instructions
Optional. To create a unique identifier for this request, the user simply
enters a nickname (e.g., 2016 Funding Year Homewood FCC Form 461).
This is the selection of the funding year the applicant is submitting the
request for.
Auto-generated by the system: This is a Universal Service Administrative
Company (USAC)-assigned unique identifier for this request.
Auto-generated by the system: Based on information for the previously
submitted FCC Form 460.This is a USAC-assigned unique identifier for
this request.
Auto-generated by the system: This is a USAC-assigned date based on
the date of submission of the request and review of the request.
Auto-generated by the system: This is a USAC-assigned date based on no
less than 28 days from the FCC Form 461 posting start date.
Auto-generated by the system: This is a USAC-assigned date, plus any
time added by the user, after which the applicant is able to enter into an
agreement with a service provider. This date must be a date after the
RFP and/or FCC Form 461 posting end date.
Auto-populated by the system: This is the name the site submitted on
the FCC Form 460.
Auto-populated by the system: This is the unique identifier assigned by
USAC to the site listed in Site Name on the FCC Form 460.

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Item # Field Description
10
Site Address

11

Consortium Name

System Generated

12

Consortium Number

System Generated

13

Consortium Address

System Generated

14

FCC Registration Number

System Generated

15

RFP Details

16

Indicate Whether a Separate
Request for Proposal (RFP) will be
Released for this Request
Letter of Agency (LOA)

17

Network Plan

RFP Details

18

Needs or Services Requested:
Category
Needs or Services Requested:
Service/Activity Details
Needs or Services Requested:
Applications & Usage
Needs or Services Requested:
Site(s) Listing
Needs or Services Requested:
Desired Contract Length

RFP Details

Purpose/Instructions
Auto-populated by the system: This is the site’s physical address, county,
city, state, zip code and geolocation the user submitted on its FCC Form
460. Geolocation only applies to a site that does not have a street
address.
Auto-populated by the system: This is the name the consortium
submitted on the FCC Form 460.
Auto-populated by the system: This is the unique identifier assigned by
USAC to the consortium listed in Site Name on the FCC Form 460.
Auto-populated by the system: This is the consortium’s address, county,
city, state, zip code and geolocation the user submitted on its FCC Form
460. Geolocation only applies to a consortium that does not have a
street address.
Auto-populated by the system: This is either the consortium or the site’s
unique FCC registration number submitted via the FCC Form 460
The user indicates whether they are using an RFP. If an RFP is used, it
must be attached to the FCC Form 461 so that it can be “released” with
the posting of the FCC Form 461.
For consortia only. The Consortium Leader is required to submit an LOA
for each eligible health care provider participating in the consortium no
later than when it submits its request for services (FCC Form 461).
For consortia only. If an applicant is a consortium, they must submit a
narrative of its Network Plan with the FCC Form 461.
The user details which category(s) of services/activities it is requesting.

RFP Details

The user details any services/activities sought with the request.

RFP Details

The user details the usage level and usage period for services/activities
requested.
The user provides information on the sites/entities included in the
request.
The user provides details on the length and type of contract requested.

19
20
21
22

Category
System Generated

RFP Details

RFP Details
RFP Details

2

Item # Field Description
23
Needs or Services Requested: Bid
Evaluation Period

Category
RFP Details

24

Needs or Services Requested:
USAC Bid Posting Period

RFP Details

25

Bidding Evaluation

RFP Details

26

Supporting Documentation

Documentation

27

Contact Person Name

RFP Details

28

Contact Person Employer

RFP Details

29

Contact Person Title

RFP Details

30

Contact Person Mailing Address

RFP Details

31

Contact Person Telephone Number RFP Details

32

Contact Person Email Address

RFP Details

33

Contact Person Fax Number

RFP Details

34

Declaration of Assistance

RFP Details

Purpose/Instructions
Optional. The user can expresses how long after the end of the FCC Form
461 28-day posting period they will need to evaluate bids. The expected
bid evaluation period is not part of the ACSD calculation.
Optional. The user may add days to the posting period beyond the
required minimum 28-day posting period. The system will only allow the
applicant to enter a date that meets or exceeds the 28-day minimum
requirement.
The user develops a weighted evaluation criteria (e.g., scoring matrix)
that demonstrates how the applicant will choose the most ‘costeffective' bid before submitting a request for services. Price must be a
primary factor, but need not be the only primary factor. A non-price
factor can receive an equal weight to price, but may not receive a
greater weight than price.
Optional. Provides an option for the user to upload and submit
supporting documents to support their request.
The user must provide the name of the person who should be contacted
with questions about this request. This could be the Primary Contact,
Additional Contact(s) or another person qualified to answer questions
relating to the request.
The user must provide the employer of the person who should be
contacted with questions about this request.
The user must provide the title of the person who should be contacted
with questions about this request.
The user must provide the mailing address of the person who should be
contacted with questions about this request.
The user must provide the telephone number of the person who should
be contacted with questions about this request.
The user must provide the email address of the person who should be
contacted with questions about this request.
The user must provide the fax number of the person who should be
contacted with questions about this request.
If user uses a consultant, service provider, or any other outside expert,
whether paid or unpaid, to submit its request, the user must provide the
3

Item # Field Description

Category

35

I certify under penalty of perjury
that I am authorized to submit this
request on behalf of the
Healthcare Provider or
consortium.

36

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

37

Certifications

Purpose/Instructions
name of the company, name of the person representing the applicant,
title of the person representing the applicant, telephone number, email
address, and physical address.
The applicant is required to provide certifications in order to receive
Healthcare Connect Fund support. For individual healthcare provider
applicants, certifications must be signed by an officer or director of the
healthcare provider. For consortium applicants, an officer, director, or
other authorized employee of the Consortium Leader must sign the
required certification.
See Item #35 Purpose/Instructions above.

See Item #35 Purpose/Instructions above.

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Item # Field Description
38
If 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 Healthcare 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.
39
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.
40
I certify under penalty of perjury
that the applicant has reviewed all
applicable requirements for the
program and will comply with
those requirements.

Category
Certifications

Purpose/Instructions
See Item #35 Purpose/Instructions above.

Certifications

See Item #35 Purpose/Instructions above.

Certifications

See Item #35 Purpose/Instructions above.

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Item # Field Description
41
I understand that all
documentation associated with
this request, including a copy of
the signed FCC Form 461, any
bids/contracts resulting from the
FCC Form 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.
42
Signature
43
Date Submitted
44
Date Signed
45
Authorized Person Name

Category
Certifications

Purpose/Instructions
See Item #35 Purpose/Instructions above.

Signature
System Generated
System Generated
Signature

The FCC Form 461 must be signed electronically.
Auto generated by system.
Auto generated by system.
This is the name of the Authorized Person signing the FCC Form 461.
This is the name of the employer of the Authorized Person signing the
FCC Form 461.
This is the FCC registration number of the Authorized Person signing the
FCC Form 461.
This is the title of the Authorized Person signing the FCC Form 461.
This is the address (can be physical address or mailing address) of the
Authorized Person signing the FCC Form 461.
This is the telephone number of the Authorized Person signing the FCC
Form 461.
This is the email address of the Authorized Person signing the FCC Form
461.

46

Authorized Person’s Employer

Signature

47

Authorized Person’s Employer FCC
Registration Number
Authorized Person’s Title/Position
Authorized Person’s Mailing
Address
Authorized Person Telephone
Number
Authorized Person Email Address

Signature

48
49
50
51

Signature
Signature
Signature
Signature

6