Form 465 RHCTP Description of Eligibility and Request for Service

Rural Health Care
Telecommunications Program
Description of Eligibility and Request for Services FCC Form 465
(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 will be
carried forward and auto-populated into the form.)
Item #
1

Field Description
FCC Form 465 Application Number

Category
System
Generated

2

Applicant’s FCC Form Nickname

Request
Information

3
4

Site Name
Site Number

Site Information
Site Information

5

Site Address

Site Information

6
7
8

Site Website
Site FCC Registration Number (FCC RN)
Employer Identification Number (EIN)

Site Information
Site Information
Site Information

9

National Provider Identifier (NPI)

Site Information

10

Organization Taxonomy Code

Site Information

1

Purpose/Instructions
Auto generated by system. This is a Universal Service
Administrative Company (USAC)-assigned unique
identifier for this request.
Optional. To create a unique identifier for this
submission, the user simply enters a nickname (e.g.,
Funding Year (FY) 2016 Homewood FCC Form 465).
This is the name of the site.
Auto generated by system. This is the unique identifier
assigned by USAC to the site listed in Site Name.
This is the site’s physical address, county, city, state, zip
code and geolocation. Geolocation is an optional field
that is only required for a site that does not have a
street address.
Optional. The website address of the site.
This is the site’s unique FCC RN identifier.
The EIN is also known as a Federal Tax Identification
Number, and is used to identify a business or non-profit
entity.
The ten-digit health care facility NPI is used on Medicare
and Medicaid claims.
This is the ten-digit Health Care Provider (HCP)
Taxonomy Code that corresponds to the NPI.

Item #
11

Field Description
Site Taxonomy Code

Category
Site Information

12

Legal Entity Name

Site Information

13

Legal Entity FCC RN

Site Information

14

Legal Entity Contact

Site Information

15

Organization Affiliation

Site Information

16

Funding Year

RFP Details

17

Eligibility Entity Type that Requests Support

Site Information

2

Purpose/Instructions
Optional. Should the Organization Taxonomy Code not
adequately describe the site, the user may add
additional Taxonomy Codes.
If applicable. 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 Site
Name.
If applicable. This is the unique FCC identifier for the
Legal Entity that owns and/or operates the site.
This is the Legal Entity’s physical address, county, city,
state, zip code, telephone, website, contact name,
email, phone number, contact employer and
geolocation. Geolocation only applies to a site that does
not have a street address.
If applicable. User identifies as being a member of a
larger collective group (e.g. consortium, association,
network, etc.) that participates in either the
Telecommunications or Healthcare Connect Fund
Programs.
This is the selection of the FY the applicant is submitting
the request for. Funding years run from July 1 through
June 30 of the following year. Available funding year
selections will be displayed by the system.
These are the eligible health care provider categories as
provided in 47 C.F.R. §54.600(a): Post-secondary
educational institution offering health care instruction,
teaching hospital or medical school; Community health
center or health center providing health care to
migrants; Local health department or agency;
Community mental health center; Not-for-profit
hospital; Rural health clinic; Skilled nursing facility;
Dedicated ER of rural, for-profit hospital; Part-time
eligible entity; Consortium of the above.

Item #
18

Field Description
Eligibility Entity Type Requests Support: If Consortium,
Dedicated Emergency Department or Part-Time Eligible
Entity
Eligibility Entity Type that Seek Support: If Community
Mental Health Center

Category
Site Information

Purpose/Instructions
The user further describes the site if they qualify as one
of these types of sites.

Site Information

20

Eligibility Entity Type Requests Support: Additional Site
Information

Site Information

21

Eligibility Entity Type that Seek Support: Additional Site
Information

Site Information

22

Needs or Services Requested: Category

RFP Details

23

Needs or Services Requested: Service/Activity Details

RFP Details

If the user chooses “Community Mental Health Center,”
then the user must submit a Community Mental Health
Center Certification, a copy of the health care provider’s
(HCP) operating license
Optional. The user has the ability to provide a brief
explanation of why the site qualifies as the category
selected.
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.
The user details which category(s) of services/activities
the site is requesting.
The user details any services/activities sought with the
request, (e.g. how the services/activities will be used or
usage level and usage period). This allows service
providers to learn what the site wants to do, so they can
propose services to meet the site’s needs.

24

Needs or Services Requested: Desired Contract Length

RFP Details

25

Needs or Services Requested: Bid Posting Period

RFP Details

19

3

The user provides details on the length and type of
contract requested.
Optional. The user may add days on to the posting
period beyond the required minimum 28-day posting
period.

Item #
26

Field Description
Bidding Evaluation

Category
RFP Details

27

Primary Contact Name

Contact
Information

28

Primary Contact Employer/Organization

29

Primary Contact Title

30

Primary Contact Mailing Address

Contact
Information
Contact
Information
Contact
Information

31

Primary Contact Telephone Number

32

Primary Contact Email Address

33

Primary Contact Fax Number

Contact
Information
Contact
Information
Contact
Information

4

Purpose/Instructions
The user develops and enters a weighted evaluation
criteria (e.g., scoring matrix) that demonstrates how the
applicant will choose the most ‘cost-effective' bid before
submitting a request for services. The applicant shall
certify to USAC that the selected provider is the most
cost-effective method of providing the requested service
or services, where the most cost-effective method of
providing a service is defined as the method that costs
the least after consideration of the features, quality of
transmission, reliability, and other factors that the
applicant deems relevant to choosing a method of
providing the required health care services. See 47
C.F.R. sec. 54.603(b)(4).
This is the name of the person who should be contacted
with questions about this request. This person must be
employed by the Legal Entity listed on this form.
This will auto-populate to be the information listed
within “Legal Entity Name.”
This is the title of the person who should be contacted
with questions about this request.
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 the 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.
This is the fax number of the person who should be
contacted with questions about this request.

Item #
34

Field Description
Additional Contact(s)

Category
Contact
Information

35

Supporting Documentation

Documentation

36

I certify that I am authorized to submit this request on
behalf of the above-named entity, that I have examined
this request, and that to the best of my knowledge,
information, and belief, all statements of fact contained
herein are true.
I certify that the health care provider (HCP) has followed
any applicable State or local procurement rules.
I certify that the telecommunications services that the
HCP receives at reduced rates as a result of the HCPs’
participation in this program, pursuant to 47. U.S.C. § 254
as implemented by the Federal Communications
Commission, will be used solely for purposes reasonably
related to the provision of health care service or
instruction that the HCP 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.
I certify that the health care provider (HCP) is a non-profit
or public entity.

Certifications

37
38

39

Purpose/Instructions
Allows the user to add additional contact person(s) to
the request. 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 (optional). This
person will be an account holder in MyPortal with access
to the site’s application forms.
Optional. This provides an option for the user to upload
and submit documents to support their request.
This certification is required in order to submit the
request for discounted services.

Certifications

See Item #36, Purpose/Instructions.

Certifications

See Item #36, Purpose/Instructions.

Certifications

See Item #36, Purpose/Instructions.

5

Item #
40

42
43

Field Description
I certify that the health care provider (HCP) is located in a
rural area. Visit the Eligible Rural Areas Search Tool on
the Telecommunications Program web page at
http://usac.org/rhc/telecommunications/tools/rural/sear
ch/search.asp or contact RHC at (800) 453-1546 for a
listing of rural areas.
Pursuant to 47 C.F.R. § 54.601 and 54.603, I certify that
the HCP that I am representing satisfies all of the
requirements herein and will abide by all of the relevant
requirements, including all applicable FCC rules, with
respect to funding provided under 47 U.S.C. § 254.
Signature
Date Submitted

44

Date Signed

45

Authorized Person

Signature
System
Generated
System
Generated
Signature

46

Authorized Person’s Employer

Signature

47

Authorized Person’s Employer FCC RN

Signature

48

Authorized Person’s Title/Position

Signature

49

Authorized Person’s Mailing Address

Signature

41

Category
Certifications

Purpose/Instructions
See Item #36, Purpose/Instructions.

Certifications

See Item #36, Purpose/Instructions.

The FCC Form 465 must be certified electronically.
Auto generated by system.

6

Auto generated by system.
This is the name of the Authorized Person signing the
FCC Form 465. This field will be auto-populated if
already within the system
This is the name of the employer of the Authorized
Person signing the FCC Form 465. This field will be autopopulated if already within the system
This is the FCC RN of the Authorized Person signing the
FCC Form 465. This field will be auto-populated if
already within the system
This is the title of the Authorized Person signing the FCC
Form 465. This field will be auto-populated if already
within the system
This is the address (can be physical address or mailing
address) of the Authorized Person signing the FCC Form
465. This field will be auto-populated if already within
the system

Item #
50

Field Description
Authorized Person Telephone Number

Category
Signature

51

Authorized Person Email Address

Signature

52

Declaration of Assistance

Request
Information

53

Third Party Authorization (TPA)

Request
Information

7

Purpose/Instructions
This is the telephone number of the Authorized Person
signing the FCC Form 465. This field will be autopopulated if already within the system
This is the email address of the Authorized Person
signing the FCC Form 465. This field will be autopopulated if already within the system
If applicable. 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 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.
If applicable, the user must provide a TPA which
provides written authorization to a third
party/consultant to complete and submit FCC Forms on
behalf of the HCP for the Telecommunications Program.