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pdfRural Health Care
Telecommunications Program
Description of Request for Funding FCC Form 466
(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
Funding Year
Category
Funding Details
2
FCC Form 466 Application Number
System Populated
3
Site Number
System Populated
4
Site Name
System Populated
5
Site Contact Information
System Populated
6
FCC Form 465 Application Number
System Populated
Purpose/Instructions
This is the selection of the funding year (FY) associated with the FCC
Form 465 submitted. Depending on the timing of the request, multiple
fund years may be available for the user to select.
Auto-populated by the system: This is a USAC-assigned unique
identifier for this request.
Auto-populated 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 was issued by USAC when the FCC
Form 465 was completed.
Auto-populated by the system: This is the name of the site submitted
on the FCC Form 465.
Auto-populated by the system: This is the site’s physical address,
county, city, state, zip code, telephone, website, contact name,
contact employer, email address and geolocation. Geolocation only
applies to a site that does not have a street address. This information
was previously submitted on the FCC Form 465.
Auto-populated by the system: This is a USAC-assigned unique
identifier for this request. This number was previously assigned on the
FCC Form 465.
1
Item #
7
Field Description
Legal Entity Name
Category
Site Information
8
Legal Entity FCC RN (FCC RN)
Site Information
9
Legal Entity Contact
Site Information
10
Billed Entity Name
Bill Payer Information
11
Billed Entity Contact Information
Bill Payer Information
12
Billed Entity FCC Registration
Number (FCC RN)
Bill Payer Information
13
Allowable Contract Selection Date
(ACSD)
System Populated
14
Number of Service Provider Bids
Contract Selection
Details
Purpose/Instructions
Auto-populated by the system: 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. This is the
name previously submitted on the FCC Form 465.
Auto-populated by the system: If applicable. This is the unique FCC
identifier for the legal entity that owns and/or operates the site. This
identifier was previously submitted on the FCC Form 465.
Auto-populated by the system: 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.
This previously supplied when the user completed the FCC Form 465.
If applicable. This is the entity that pays the bills of the service
provider for the site. This may be the site itself, or it may be the
“parent” organization, association, consortium, etc. to which the site
belongs.
If applicable. This is the Billed Entity’s physical address, county, city,
state, zip code, telephone, website, contact name, contact employer,
email address and geolocation.
Auto-populated by the system: This is the unique FCC identifier for the
Legal Entity. This number was previously supplied when the user
completed the FCC Form 465.
Auto-populated by the system: This is a USAC-assigned date (at least
28 days after the description set forth in the HCP’s Form 465 is posted
on the RHC website). This date expresses the earliest date (ACSD) on
which the HCP may sign an agreement or otherwise select a carrier to
provide services to the HCP.
The number of service providers who bid on the request for services in
response to the FCC Form 465.
2
Item #
15
Field Description
Multiple Sites
Category
Funding Details
16
498 ID of Selected Service
Provider(s)
Funding Details
17
Selected Service Provider Name(s)
Funding Details
18
Selected Service Provider Contact
Funding Details
19
Service Provider Selection Date
Funding Details
20
Funding Details
21
Continuation with Current Service
Provider
Contract ID
22
Contract Reference Number
Funding Details
23
Contract Friendly Name
Funding Details
Funding Details
Purpose/Instructions
If applicable. If the HCP is a mobile rural health care provider, it must
list the names, full addresses, expected schedule, duration of visits to
all sites to be served, and number of patients served at each location
by the mobile HCP during the funding year. The HCP must verify that
each of the sites is rural, or prorate the support request to cover only
the time when the mobile health care provider will operate in the
rural area.
The selected Service Provider’s 498 ID (formerly the Service Provider
Identification Number (SPIN)). There may be multiple service
providers should the circuit have multiple connections.
Auto-populated by the system: This name is based on the 498 ID
entered by the user. There may be multiple service providers should
the circuit have multiple connections.
Auto-populated by the system: This contact information is based on
the 498 ID entered. This is the service provider’s physical address,
county, city, state, zip code, telephone, website, contact name, email,
phone number, contact employer and geolocation. There may be
multiple service providers should the circuit have multiple
connections.
The date that the line item service provider was selected. The HCP or
its authorized representative must not select a service provider or
enter into a contract or purchase an agreement with a service
provider until at least 28 days have elapsed since the Form 465 was
posted on the RHC website.
The user indicates if the selected service provider is its current service
provider.
The unique identifier assigned by USAC to a contract or service
agreement. This identifier helps the applicant identify the contract in
the future and apply in subsequent funding years.
The user provides a tariff, contract and other document reference
number for each segment of the circuit.
Optional. To create a unique identifier for this request, the user simply
enters a nickname (e.g., Smith Telecommunications FY 2016).
3
Item #
24
Field Description
Expense/Service Type
Category
Funding Details
25
Multiple Service Providers
Funding Details
26
27
Circuit Bandwidth
Circuit ID
Funding Details
Funding Details
28
Circuit Diagram
Funding Details
29
Total Billed Circuit Miles
Funding Details
30
Maximum Allowable Distance
Funding Details
31
Circuit Start Location
Funding Details
32
Circuit End Location
Funding Details
33
Satellite Delivery
Funding Details
34
Inclusion of Ineligible
Services/Sites
Funding Details
Purpose/Instructions
The user selects the expense/service type (from a list) for the line
item. (e.g. T-1)
The user indicates if its service is provided using multiple connections
and is provided by multiple service providers; If “YES,” then the user
provides further information on the individual service providers. The
information collected for multiple service providers is the same
fields/inputs as that which is collected for one service provider for the
entire circuit.
The user enters the bandwidth for expense/service type.
The user enters a service provider-specific identifier assigned to the
connection between two locations for the line item. The Circuit ID is
located on the service provider invoice.
If applicable. If HCP is part of a large organization (consortium,
network, etc.) or uses multiple service providers for the service, then
it must include a diagram to show how the sites interconnect and
which carrier(s) provide each circuit segment.
Auto-calculated by the system. The sum of all miles billed by all
services providers for that circuit.
Auto-populated by the system: Based on information provided on the
FCC Form 465.
The physical location and/or Site Number where the circuit originates
for the line item.
The physical location and/or Site Number where the circuit terminates
for the line item.
The user selects if the service is delivered by satellite. If “Yes,” then
the user must provide the urban and rural rates for the functionally
similar wireline service.
The user indicates if the line item includes services or sites that are
ineligible.
4
Item #
35
Field Description
Percentage of Expense Eligible
Category
Funding Details
36
Percentage of Usage Eligible
Funding Details
37
38
Billing Account Number (BAN)
Initial Contract Length
39
Contract Expiration Date
40
Number of Contract Extensions,
Options and/or Upgrades
Funding Details
Contract Selection
Details
Contract Selection
Details
Contract Selection
Details
41
Combined Optional Extension(s)
Length
Contract Selection
Details
42
Evergreen Review
Contract Selection
Details
43
Expected Service Start Date
44
Actual Rural Rate per Month
Contract Selection
Details
Funding Details
45
Service Level Agreement (SLA)
46
47
Quantity of Items
Processing: Type Funding Request
Contract Selection
Details
Funding Details
Funding Details
Purpose/Instructions
The user enters the percentage of the expense that is eligible for
support. If the entire expense is eligible, enter “100%”. For example, a
vendor may provide a bundle that includes both eligible and ineligible
services. If percentage is less than 100%, then the user must briefly
explain how the percentage was derived.
The user enters the percentage of the usage that is eligible for
support. If all of the usage is eligible, enter “100%”. An applicant
should use this column to indicate the eligible portion of a connection
that is used by both eligible and ineligible sites.
The line item BAN listed on the service provider’s bill.
The length of the initial contract excluding voluntary options. Does not
include any optional extensions.
The date the signed contract will expire. Does not include any optional
extensions.
If the contract includes voluntary options to extend the term of the
contract and/or upgrade services, then the user enters the number of
such voluntary options.
If the contract includes one or more voluntary options to extend the
term of the contract, then the user enters the combined length of all
the voluntary options.
The user states that the contract submitted with the funding request
shall be reviewed for an evergreen endorsement (thereby allowing a
competitive bidding exemption for the life of the contract).
The date service is expected to start.
The amount the site pays per month or the expected amount to be
paid per month for the service.
The indication that the applicant’s contract with the service provider
includes an SLA.
The number of items the applicant is seeking under this line item.
The user indicates the type of funding the applicant is requesting (e.g.
multi-year, month-to-month, etc.)
5
Item #
48
Field Description
Billed Circuit Miles
49
Monthly Mileage Charges
50
Cost per Mile per Month
51
Installation Urban Rate Charge
52
Installation Rural Rate Charge
53
Monthly Urban Rate Charge
54
55
Taxes & Fees Per Expense Period
Supporting Documentation
Category
Funding Details:
Mileage-based
Requests and
Comprehensive Rate
Request
Funding Details:
Mileage-based
Requests and
Comprehensive Rate
Request
Funding Details:
Mileage-based
Requests and
Comprehensive Rate
Request
Funding Details:
Comprehensive Rate
Request
Funding Details:
Comprehensive Rate
Request
Funding Details:
Comprehensive Rate
Request
Funding Details
Documentation
Purpose/Instructions
The billed miles for each connection.
The monthly mileage charges for the service.
The cost per mile per month for each connection.
The one-time urban rate charge for the service listed in any city in the
site’s state with a population of 50,000 or more.
The amount the service provider will charge the billed entity to install
the service listed.
The monthly urban rate for the service listed.
The taxes and fees for the line item.
Optional. This option allows the user to upload and submit
documents to support their request.
6
Item #
56
57
58
Field Description
I certify that the above named
entity has considered all bids
received and selected the most
cost-effective method of providing
the requested service or services.
The "most cost-effective service" is
defined in the 47 C.F.R. §
54.603(b)(4) as the service
available at the lowest cost after
consideration of the features,
quality of transmission, reliability,
and other factors that the health
care provider deems necessary for
the service to adequately transmit
the health care services required
by the health care provider.
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 universal service
benefits provided under 47 U.S.C. §
254. I understand that any letter
from RHC that erroneously states
that funds will be made available
for the benefit of the applicant
may be subject to rescission.
I hereby certify that the billed
entity will retain complete billing
records for the service for five
years.
Category
Certifications
Purpose/Instructions
This certification is required in order to submit the funding request.
Certifications
See #56, Purpose/Instructions.
Certifications
See #56, Purpose/Instructions.
7
Item #
59
60
61
62
63
64
65
66
67
68
69
Field Description
I certify that I am authorized to
submit this request on behalf of
the above-named Billed Entity and
HCP, and that I have examined this
form and attachments and that to
the best of my knowledge,
information, and belief, all
statements of fact contained
herein are true.
Signature
Date Submitted
Date Signed
Authorized Person Name
Authorized Person’s Employer
Category
Certifications
Purpose/Instructions
See #56 Purpose/Instructions.
Signature
System Populated
System Populated
Signature
Signature
Authorized Person’s Employer FCC
RN
Authorized Person’s Title/Position
Authorized Person’s Mailing
Address
Authorized Person Telephone
Number
Authorized Person Email Address
Signature
The FCC Form 465 must be certified electronically.
Auto populated by system.
Auto populated by system.
This is the name of the Authorized Person signing the FCC Form 465.
This is the name of the employer of the Authorized Person signing the
FCC Form 465.
This is the FCC RN of the Authorized Person signing the FCC Form 465.
Signature
Signature
Signature
Signature
This is the title of the Authorized Person signing the FCC Form 465.
This is the address (can be physical address or mailing address) of the
Authorized Person signing the FCC Form 465.
This is the telephone number of the Authorized Person signing the FCC
Form 465.
This is the email address of the Authorized Person signing the FCC
Form 465.
8
| File Type | application/pdf |
| Author | Catriona Ayer |
| File Modified | 2016-07-22 |
| File Created | 2016-07-11 |