Form 460 RHCP Description of Eligibility and Registration

FCC Form 460

OMB Approved 3060-0804
Estimated Time Per Response: 1 hour

Rural Health Care (RHC) Universal Service
Eligibility and Registration Form

Read instructions thoroughly before completing this form. Failure to comply may cause delayed or denied funding.

Block 1: General Information
1 Date Submitted:
2 Applying to:

Determine eligibility of an HCP site
Determine eligibility of Consortium
Register an off-site data center

Register an ineligible site
Register an off-site administrative office

2a If applying as an off-site data center, list all sites (eligible and ineligible) that will use the services of this data center.
2b If applying as an off-site administrative office, list all sites (eligible and ineligible) that will use the services of this
administrative office.
Block 2: Site Information – Physical Site
Enter the actual physical location of the site.

3 HCP Number

4 Site Name

5 Name of Legal Entity
6 Enter FCC Registration Number (FCC RN) for Line 5 legal entity:
6a If the Line 5 legal entity does not have an FCC RN and only plans to participate as a consortium member, applicant
may enter FCC RN for the Consortium (see instructions for more detail):
7 Site Contact Name
8 Address Line 1
9 Address Line 2

10 County

11 Geo Location (if no street address)
12 City
15 Phone

13 State
Ext.

14 Zip Code

16 Email

Block 3: Consortium Information
17 HCP Number
18 Name of Consortium
19 Is the Consortium a legal entity?

Yes

No

If yes, Consortium FCC RN:

20 Consortium has a written agreement allocating legal and financial responsibility.

Yes

No

If yes, submit the agreement to USAC. If no, see instructions regarding the default entity that bears legal and financial responsibility for the
consortium’s activities in connection with the Healthcare Connect Fund.

21 Consortium Leader Type:
The Consortium
An eligible HCP participating in the Consortium
HCP Number: ________________________

Ineligible State organization
Ineligible public sector (government) entity
Ineligible non-profit 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. Submit any such request for exemption.

22 Consortium Leader Contact Information

23 Name of Consortium Leader

Consortium applicants are required to have a Letter of Agency from each eligible HCP that authorizes the Consortium to file forms on the HCP’s
behalf. Submit a Letter of Agency for each eligible HCP.

24 List participating sites by HCP Number (eligible/ineligible)
Block 4: Contact Information
25 Primary Account Holder/Project Coordinator Name
26 Employer
27 Address Line 1

Same as Physical Location

28 Address Line 2
29 City
32 Phone #

30 State
Ext.

33 Email

31 Zip Code

Block 2: Site Information – Physical Site
34 Secondary Account Holder (Application Contact/Assistant Project Coordinator)
35 Employer
36 Address Line 1

Same as Primary Account Holder Address

37 Address Line 2
38 City

39 State

41 Phone #
Block 5: Eligibility Category

Ext.

40 Zip Code

42 Email

43 Select the category that describes the HCP site
(If seeking an eligibility determination for a Consortium, “Consortium of the above” will be automatically selected)

A. Community health center or health center providing health care to migrants
B. Community mental health center
C. Local health department/agency
D. Non-profit hospital
E. Part-time eligible entity located in an ineligible facility
F. Post-secondary educational Institution offering health care instruction, teaching hospital, or medical school
G1. Rural health clinic
G2. Is this a mobile rural health care provider?

Yes

No

H. Dedicated ER of rural, for-profit hospital
I. Consortium of the above
44 Provide a brief explanation of why this site qualifies as the organization type selected above:

Block 6: Additional Information
45 Non-Profit Tax ID (EIN):
46 National Provider Identifier:
Explanation if necessary (see instructions)

47a Organization Taxonomy Code:
47b Site Taxonomy Code:
Explanation if necessary (see instructions)

48 If a Non-Profit Hospital, is this a Critical Access Hospital?

Yes

49 If a Non-Profit Hospital, how many licensed patient beds are at the site?
50 Is the site location:

On Tribal lands

_______________

Otherwise affiliated with a Tribe

Operated by the Indian Health Service
51 [Reserved]

No

N/A

52 [Reserved]

Block 7: Certifications and Signatures
53

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

54

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.

55

If applying as an individual health care provider site, I certify that the health care provider is a non-profit or
public entity and that the site is located in a FCC designated rural area, or is grandfathered rural pursuant to
47 C.F.R. Sec. 54.600(b)(2).

56

If applying as a consortium, I certify that the eligible health care providers participating in the consortium are
non-profit or public entities.

57

I understand that all documentation associated with this form 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.

58

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 forms for the funding year(s) for which support is
sought.
FCC Form 460

Block 7: Certifications and Signatures
59 Signature

60 Date

61 Printed Name of Authorized Person
62 Title/Position of Authorized Person
63 Phone
65 Employer

Ext.

64 Email
66 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
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 1 hour 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.

FCC Form 460

OMB Approved
3060-0804
Estimated time per response: 1 hour

FCC Form 460 Instructions
Rural Health Care Universal Service
Eligibility and Registration Form

I.

PURPOSE OF FORM............................................................................................................ 2

II.

FILING REQUIREMENTS AND GENERAL INSTRUCTIONS............................................... 3

A.

Who is Eligible to Receive Support from the Fund............................................................. 3

B.

Registration of Ineligible HCP Sites ................................................................................... 4

C.

Registration of Off-Site Administrative Offices and Off-Site Data Centers......................... 4

D.

When to File ....................................................................................................................... 4

E.

Where to File ...................................................................................................................... 5

F.

Next Steps.......................................................................................................................... 5

G.

For More Information........................................................................................................5

III.

SPECIFIC INSTRUCTIONS FOR FILING FORM 460 ....................................................... 6

A.

Block 1: General Information............................................................................................. 6

B.

Block 2: Site Information – Physical Location ................................................................... 6

C.

Block 3: Consortium Information ....................................................................................... 7

D.

Block 4: Contact Information ............................................................................................. 9

E.

Block 5: Eligibility Information ........................................................................................... 9

F.

Block 6: Additional Information........................................................................................ 10

G.

Block 7: Certifications and Signatures ............................................................................ 11

IV.

REMINDERS..................................................................................................................... 11

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I.

PURPOSE OF FORM

Submitting the Federal Communications Commission (FCC) Form 460 is the first step health
care providers (HCPs) must take to participate in the universal service support mechanism’s
Healthcare Connect Fund (Fund).1 One Form 460 must be completed for each site, including
each eligible HCP site, ineligible site, off-site data center, and off-site administrative office.
Each consortium and each and every HCP site, including those participating in a consortium,
must obtain an eligibility determination via the Form 460 to receive Fund support. If
participating in a consortium, an HCP may opt to allow the Consortium Leader to file a Form 460
on its behalf to determine its eligibility. In addition, the Form 460 is used to register ineligible
HCP sites, off-site data centers, and off-site administrative offices. The Form 460 is also used
to notify the Universal Service Administrative Company (USAC) when information for a site or
consortium has changed. See When to File below for more information about when notification
is required.
•

An individual applicant must file a Form 460 for itself and a separate Form 460 for any
associated off-site administrative office or off-site data center.

•

Each participating entity of a consortium must file a Form 460 to determine the eligibility
of that physical location, or the register an ineligible entity, off-site data center and offsite administrative offices.

•

A consortium applicant must file a Form 460 identifying all of the sites on its network.
This includes eligible sites, ineligible sites, off-site data centers and off-site administrative
offices. A consortium applicant may also file a Form 460 on behalf of any site on its
network to determine that site’s eligibility, at the option of the HCP.
Consortium applicants must keep their Form 460s current to reflect their current
membership.

All individual HCPs, consortia, and consortium members must obtain an eligibility determination
via Form 460 to receive Fund support. The eligibility determination must occur before the start
of competitive bidding, which is initiated through the submission of FCC Form 461.
Applicants must complete and submit all forms online with USAC, not the FCC. See Where to
File below for more information.
The Form 460 is completed for each physical location and the information is used to
automatically populate, where applicable, the other forms for this funding year and subsequent
funding years. Applicants are required to maintain the accuracy of each Form 460. See When
to File below for more information.

1

An HCP that is only participating in the Rural Health Care Telecommunications Program is not required
to file Form 460. See http://www.usac.org/rhc/telecommunications/default.aspx.

2

All applicants are encouraged to review the FCC’s Healthcare Connect Fund Order, FCC 12150, available at http://hraunfoss.fcc.gov/edocs_public/attachmatch/FCC-12-150A1.pdf, and the
FCC’s rules at 47 C.F.R. § 54.600 et seq., available at http://www.ecfr.gov.
II. FILING REQUIREMENTS AND GENERAL INSTRUCTIONS
A. Who is Eligible to Receive Support from the Fund
1. Eligible Types of HCP Sites:
Eligible HCP sites must be public or non-profit, and must qualify under one of the following
categories:
•
•
•
•
•
•
•
•

Post-secondary educational institutions offering health care instruction, including
teaching hospitals and medical schools;
Community health centers or health centers providing health care to migrants;
Local health departments or agencies;
Community mental health centers;
Not-for-profit hospitals;
Rural health clinics;
Dedicated emergency room of rural, for-profit hospitals; or
Consortia of health care providers consisting of one or more entities described
above.

In addition, connections and network equipment associated with off-site data centers and
off-site administrative offices are eligible for support, subject to certain restrictions.
2. Limitation on Non-Rural HCP Sites:
•

Rural public or non-profit HCP sites are eligible to receive support individually or as
part of a consortium.

•

Non-rural public or non-profit HCP sites are eligible to receive support only as part of
a consortium, and subject to certain restrictions (see below).

3. Applying as an Individual HCP Site:
Only public or non-profit HCP sites located in rural areas may apply for support on an
individual basis. An HCP site can determine if it is in an area that meets the FCC definition
of rural by consulting the USAC Rural Health Care website at
http://www.usac.org/rhc/telecommunications/tools/Rural/search/search.asp. HCPs located
in rural areas under the FCC’s pre-July 1, 2005 definition, and that have been receiving
support from the universal service rural health care support mechanism since that time, will
be “grandfathered” and will continue to be treated as if they were located in a rural area for
the purposes of determining eligibility. If a grandfathered HCP site moves to a new address,
USAC will determine whether the new address would also have been considered rural under
the pre-July 1, 2005 definition. If so, the HCP will continue to retain its rural classification. If
not, the HCP becomes non-rural and is not eligible for support on an individual basis.

3

4. Applying as a Consortium:
Both rural and non-rural eligible HCP sites may apply for support as part of a consortium. A
consortium is a group of two or more health care provider sites that request support through
a single application. In addition, ineligible sites may participate as part of a consortium,
although they are not eligible to receive support from the Fund and must pay full cost (fair
share) for all services, network equipment, and/or facilities received through the consortium.
Each ineligible site participating in a consortium must be registered using Form 460.
Non-rural public or non-profit HCP sites may receive support only if they are part of a
consortium that includes a majority (more than 50 percent) of eligible HCP sites that are
rural. A consortium must achieve compliance with this requirement within three years of the
filing date of its first request for funding (FCC Form 462). Non-rural hospitals with 400 or
more licensed patient beds also are limited in the amount of support per year. See 47
C.F.R. § 54.630(c) for more information about the limitation.
B. Registration of Ineligible HCP Sites
Each ineligible HCP site participating in a consortium must register with USAC, using Form 460.
The Consortium Leader typically will file the Form 460 on behalf of the ineligible HCP site.
Although the Consortium Leader is not required to submit a Letter of Agency for an ineligible
HCP site, the Consortium Leader must still certify that it has the authority to submit this form on
behalf of the ineligible site.
C. Registration of Off-Site Administrative Offices and Off-Site Data Centers
An applicant must register each off-site administrative office and off-site data center for which it
requests support. Off-site administrative office and off-site data center themselves are not
considered eligible health care providers. However, connections and network equipment
associated with off-site administrative offices and off-site data centers used by eligible health
care providers are eligible for support. See 47 C.F.R. § 54.637 for the definitions of off-site data
center and off-site administrative office and for the restrictions associated with funding for
connections and network equipment associated with such sites.
Both individual and consortium applicants must provide a list of all HCP sites (eligible and
ineligible) that will use the supported connections and network equipment associated with each
off-site data center and off-site administrative office. Submit FCC Form 460 for the HCP sites
(eligible and ineligible) first, since you will need the HCP number assigned by USAC for each
HCP site in order to register an off-site data center or off-site administrative office.
D. When to File
Applicants may submit the Form 460 prior to, or along with, their request for services (FCC
Form 461). The purpose of the Form 460 is to determine the eligibility of particular HCP sites or
to register ineligible sites, off-site administrative offices, or off-site data centers. The purpose of
the Form 461 is to provide the necessary information to initiate the competitive bidding process.
Applicants are encouraged to submit all necessary Form 460(s) at least 30 days prior to filing
Form 461. Applicants can choose to submit the Form 460(s) and Form 461 concurrently, but
Applicants are cautioned that the Form 461 will not be posted until USAC has confirmed eligibility
of the HCP site(s) (and consortium, if applicable).
4

If an applicant is claiming an exemption from competitive bidding (and thus not filing a Form
461), the applicant must submit a Form 460 prior to or with its request for funding (FCC Form
462). In such a case, a funding commitment will not be issued until USAC has confirmed
eligibility of the HCP site(s) (and consortium, if applicable).
No further eligibility determination is required for HCP sites that have previously received an
eligibility determination under the Telecommunications Program or the RHC Pilot Program.
However, applicants are required to complete and submit the Form 460 to USAC for each such
site.
All applicants are required to submit an updated Form 460 within 30 days of a material change.
Examples include (1) a change in a site’s name, site location, contact information or eligible
entity type, (2) for non-rural hospitals, an increase to 400 or more licensed patient beds, or (3) a
change in any factor that would affect a cost allocation and/or fair share calculation. If in doubt,
the applicant should contact USAC for additional guidance.
E. Where to File
Applicants are required to complete and submit all forms online through USAC’s RHC “My Portal”
website at https://forms.universalservice.org/usaclogin/login.asp. A Form 460 is required to be
submitted through this link to create an online account. Instructions on how to file electronically
are also found at USAC’s RHC website at http://www.usac.org/rhc/tools/applicantlogin/applicant-login-info.aspx. Applicants without adequate Internet access to submit the forms
online should contact USAC’s Rural Health Care Division (RHC) (1-800-453-1546 or [email protected]) to make alternative arrangements.
Applicants must file all forms with USAC and not the FCC.
F. Next Steps
USAC will notify the applicant within 30 calendar days after submitting the Form 460 of USAC’s
eligibility determination, of USAC’s request for more information, or of USAC’s need for
additional time to process the form. If USAC determines that the HCP site is ineligible, USAC
will automatically register the HCP site as an “ineligible site” without any additional action by the
applicant.
After receiving an eligibility determination, the individual HCP site or consortium may then
proceed to the competitive bidding stage of the process by submitting an FCC Form 461 (or if
the Form 461 is already filed, USAC will post the Form 461 to start the competitive bidding
period).
G. For More Information
Contact USAC’s Rural Health Care Division (RHC) at 1-800-453-1546 between 9:00 a.m. and
6:00 p.m. EST, Monday through Friday or at [email protected].

5

III. SPECIFIC INSTRUCTIONS FOR FILING FORM 460
A. Block 1: General Information
Line 1: The date submitted will be automatically generated.
Line 2: Select the appropriate option that describes why the applicant is submitting this form.
Line 2a (Only complete if registering an off-site data center): Requires a list of eligible and
ineligible sites, by HCP number, that will use the supported connections and/or network
equipment associated with the off-site data center. The HCP number is a unique identifier
assigned by USAC to all sites, eligible and ineligible.
Line 2b (Only complete if registering an off-site administrative office): Requires a list of
eligible and ineligible sites, by HCP number, that will use the supported connections and/or
network equipment associated with the off-site administrative office.
B. Block 2: Site Information – Physical Location
Only complete Block 2 when using this form to seek an eligibility determination of an HCP site, or
when registering an ineligible site, off-site data center, or off-site administrative office. The
information required in this block applies to the physical location of the site. Do not enter a P.O.
Box or a rural route address. See Lines 8 -14 instructions for more details.
Line 3: Requires providing the HCP number (a unique identifier assigned by USAC to all sites,
eligible and ineligible), if previously provided by USAC. If USAC has not previously provided an
HCP number for the site, leave this field blank.
Line 4: Requires providing the name of the site. This name will be automatically populated on
all forms associated with the HCP number.
Line 5: Requires providing the name of the legal entity that owns and/or operates the site. If
registering an off-site data center, provide the legal entity that will purchase the connections and
network equipment associated with the off-site data center.
Line 6: Requires providing an FCC Registration Number (FCC RN). If the legal entity named in
Line 5 has an FCC RN, the applicant must enter the Line 5 legal entity’s FCC RN in Line 6. If
the Line 5 legal entity does not have an FCC RN and plans only to apply as part of a consortium,
the applicant may enter the FCC RN of the Consortium in Line 6a.
All applicants must obtain an FCC RN, if they do not already have one. Consortium applicants
may obtain a single FCC RN for the consortium as a whole, if desired (i.e. instead of requiring
each participating site to obtain a separate FCC RN).
An FCC RN is a ten digit number that is assigned to a business or individual registering with the
FCC, and is used to uniquely identify the business or individual in all of its transactions with the
FCC. Obtaining an FCC RN is a simple process that can typically be completed within minutes
through the FCC’s website at https://fjallfoss.fcc.gov/coresWeb/publicHome.do. If you do not
have adequate Internet access to complete this process online, call the FCC’s FRN Help

6

Desk/Administrator number at (877) 480-3201 (8 a.m. to 6 p.m. Eastern Time) to obtain
information on how to obtain an FCC RN by mail.
Lines 7, 15 and 16: Requires providing the name, phone number and email of a contact person
located at the physical site. The site contact person is not necessarily the same person who will
be contacted if there are questions about the application (see Block 4 below). In the case of an
off-site data center, the site contact person is not required to be physically located at the site.
Lines 8-10, 12-14: Requires providing the site’s physical address, county, city, state and zip
code.
Line 11: Only if the site does not have a street address, provide geo-location information (i.e.,
latitude and longitude) in Line 11. Otherwise, leave Line 11 blank.
C. Block 3: Consortium Information
HCPs applying as a consortium must identify a legal entity that will be the lead entity for the
consortium (Consortium Leader). The consortium and the Consortium Leader can be the same
legal entity, but are not required to be. For example, the consortium may prefer to designate
one of its HCP members, an ineligible state government agency, or a non-profit organization as
the Consortium Leader. The consortium need not be a legal entity. However, in order for the
consortium to be the Consortium Leader, it must be a legal entity. If the Consortium Leader is
an ineligible entity, the Consortium Leader is prohibited from receiving support from the Fund. If
the Consortium Leader is an eligible HCP, the HCP may receive support while serving as
Consortium Leader.
State organizations, public sector (governmental) entities (including Tribal governments), or nonprofit entities may serve as Consortium Leaders or provide consulting assistance to the
consortium if they do not participate as potential vendors during the competitive bidding process.
Conversely, if such entities wish to provide eligible services, network equipment, or facilities to
the consortium, they are prohibited from simultaneously serving as the Consortium Leader.
Vendors that plan to bid to provide supported services, network equipment, or facilities cannot
provide consulting or other expertise to the consortium to assist it in developing its request for
services (Form 461). Applicants will be required to disclose entities who have assisted with
preparation of the request for services on Form 461.
Certain entities, such as state governmental entities, may be large enough to institute an
organizational and functional separation between staff acting on behalf of the part of the
organization performing the vendor functions and staff providing application assistance. State
organizations, public sector entities, or non-profit entities may obtain an exemption from this
prohibition by making a showing to USAC that there is a functional separation within the
organization. Attach any such request for exemption to Form 460. The exemption must be
obtained before the consortium begins preparing its request for services.
In addition to designating an entity/organization as the Consortium Leader, consortia must
designate an individual (person) as the Project Coordinator. See Block 4 below.
Line 17: Requires providing the HCP number of the consortium (a unique identifier that will be
assigned by USAC to the consortium), if previously provided by USAC. If USAC has not
previously provided an HCP number for the consortium, leave blank and USAC will supply. The
consortium will need an HCP number even if the consortium is not a legal entity. If the
7

Consortium Leader is an eligible HCP participating in the consortium, both the eligible HCP
(Consortium Leader) and the consortium itself would each have a unique HCP number.
Line 18: Requires the name of the consortium. If the consortium is a legal entity, provide the
name of the legal entity.
Line 19: Requires indicating if the consortium is a legal entity. If the consortium is a legal entity,
provide the required FCC RN. See above instructions for Line 6 for more information on how to
obtain an FCC RN.
Line 20: Requires the applicant to indicate whether 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 Fund. The
consortium may allocate legal and financial responsibility differently as it finds appropriate (except
for the functions listed in 47 C.F.R. § 54.631(c)(2)-(6)), provided that the allocation is
memorialized in a formal written agreement between the Consortium Leader and the consortium
as a whole and/or its individual members. The Consortium Leader must submit any such
agreement to USAC for approval prior to or with the FCC Form 461. The agreement should
clearly identify the party(ies) responsible for repayment if fund recovery is necessary at a later
date. USAC will provide in writing – by the expiration of the 28-day competitive bidding period –
either approval or an explanation as to why the agreement does not provide sufficient clarity
about the parties responsible for repayment.
If the consortium does not have an agreement, the Consortium Leader will be the responsible
entity if audits or other investigations by USAC or the FCC reveal violations of the program rules
by the consortium, with the individual consortium members being jointly and severally liable if
the Consortium Leader dissolves or files for bankruptcy.
For more information, see paragraph 206 of the Healthcare Connect Fund Order.
Line 21: Select the appropriate option that describes the type of Consortium Leader. If the
Consortium Leader is an eligible HCP participating in the consortium, provide the HCP number of
the eligible HCP. If the eligible HCP has more than one HCP number, enter the HCP number of
the site where the Project Coordinator is located. See instructions to Block 4 below for more
information on the Project Coordinator.
Lines 22 and 23: Requires contact information, include the address, city, state, and zip, for and
the name of the Consortium Leader. This should be the organization that will serve as the main
point of contact with USAC and the FCC and who will act on behalf of the consortium members
throughout the application process and the funding, invoicing, and post-invoicing periods.
Line 24: List the HCP numbers of all sites (eligible and ineligible) participating in the
consortium. The Consortium Leader is required to obtain a Letter of Agency from each eligible
HCP authorizing the Consortium Leader to file forms on the HCP’s behalf. The Consortium
Leader is required to submit a Letter of Agency for each eligible HCP participating in the
consortium no later than when it submits its request for services (Form 461). See 47 C.F.R. §
54.632. No Letter of Agency is required for an ineligible HCP site, but the Consortium Leader is
still required to certify that it has the authority to submit this request on behalf of the ineligible
site. More information on Letters of Agency may be found at: www.usac.org/rhc/healthcareconnect.

8

D. Block 4: Contact Information
The Consortium Leader (or HCP, if participating individually) must designate a Primary Account
Holder for purposes of interacting with USAC. For consortia, the Project Coordinator should also
be the Primary Account Holder. The Project Coordinator/Primary Account Holder must be an
officer, director, or other authorized employee of the Consortium Leader (or, HCP, if participating
individually) and may not be a consultant. See 47 C.F.R. § 54.649.
The Primary Account Holder has the ability to view, create, and enter data in forms, and
electronically certify, sign and submit forms, on behalf of the consortium (or HCP, if participating
individually). The Primary Account Holder is the person responsible for granting access to and
managing the consortium’s (or HCP’s, if participating individually) online account information.
The Primary Account Holder may designate one or more Secondary Account Holders with
varying levels of access to the consortium’s account (or HCP’s account, if participating
individually). Learn more by viewing the My Portal: Managing Account Holders video tutorial at:
http://usac.org/rhc/telecommunications/outreach/online-learning.aspx.
A Secondary Account Holder (also known as an Application Contact or Assistant Project
Coordinator) will have access to forms and have the ability to answer specific questions about
the applications associated with a funding request. In addition, a Secondary Account Holder
has full access, including the ability to sign, certify, and submit forms on behalf of the applicant,
if the Secondary Account Holder is a director, officer, or authorized employee of the Consortium
Leader (or, a director, officer, or authorized employee of the HCP, participating individually).
The Project Coordinator or Primary Account Holder may choose to engage a third-party (e.g.,
consultant) and can assign Tertiary Account Holder rights to that third-party. However, a Tertiary
Account Holder that is a third-party is prohibited from certifying, signing, or submitting forms,
unless USAC receives, prior to the submission of the forms or documentation, a written, dated,
and signed authorization from the relevant officer, director, or other authorized employee stating
that the individual HCP or Consortium Leader accepts all potential liability from any errors,
omissions, or misrepresentations on the forms and/or documents being submitted by the third
party. Attach the required third-party authorization.
Lines 25-33: Require the name, employer, address, and contact information for the Primary
Account Holder/Project Coordinator.
Lines 34-42: Require the name, employer, address, and contact information for the Secondary
Account Holder (Application Contact/Assistant Project Coordinator).
E. Block 5: Eligibility Information
This block is only required if seeking an eligibility determination of an HCP site or of a
Consortium. Otherwise, leave this Block blank.
Line 43: Requires selecting the category that describes the type of health care provider
requesting an eligibility determination. Only public or non-profit health care providers that
qualify under one of the categories listed in Block 5 are eligible for Fund support. If seeking an

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eligibility determination for a Consortium, eligibility category “Consortium of the above” will be
automatically selected.
Line 44: Applicants are required to provide a brief explanation of why the HCP site qualifies as
the HCP type selected in Line 43. This information will be used to determine the eligibility status
of the site. For example, the explanation may include a description of the services provided by
the organization or licensing information. If appropriate, supporting documentation (such as a
state license) may be uploaded when completing this section. Consortium applicants will
provide a brief description of their consortium.
F. Block 6: Additional Information
If seeking an eligibility determination for an HCP site, complete Lines 45-50. If seeking an
eligibility determination for a Consortium, only complete Line 45 in this block. Otherwise, leave
this Block blank.
Line 45: For an HCP site, enter the non-profit tax identification number for the legal entity listed
in Line 5. For a consortium, enter the non-profit tax identification number for the legal entity
listed in Line 18 (if the consortium is a legal entity) or Line 23 (if the consortium is not a legal
entity).
If the legal entity is not a non-profit entity, provide the Employer Identification Number (EIN).
Line 46: Provide the ten-digit health care facility National Provider Identifier (NPI) used on
Medicare and Medicaid claims. IMPORTANT: This should be the organizational NPI, not an
individual practitioner NPI. An NPI lookup by name and address can be found at:
https://npiregistry.cms.hhs.gov/NPPESRegistry/NPIRegistryHome.do.
If the applicant is unsure of how to determine the appropriate NPI to provide, contact the
facility’s billing department for assistance. If the applicant does not have an NPI (for example a
facility that does not bill) or the NPI Organization or DBA Name or Business Practice Location do
not match the name and address on this application, provide a brief explanation in line 46.
Line 47a: Provide the ten-digit Healthcare Provider Taxonomy Code for the site associated
with the NPI in line 46 (for the organization).
Line 47b: If the provided taxonomy code is not the appropriate taxonomy code for the site,
review the codes and select the appropriate code for this site. If applicant does not provide a
taxonomy code or the code is not one associated with the NPI, provide a brief explanation of
eligibility.
Line 48: If the HCP selected “non-profit hospital” in Block 5, select “yes” here if it has been
designated as a Critical Access Hospital by the U.S. Department of Health and Human
Services, Centers for Medicare & Medicaid Services.
Line 49: If the HCP selected “non-profit hospital” in Block 5, enter the number of licensed
patient beds. Licensed patient beds are the maximum number of beds the hospital is licensed
to operate.
Line 50: Indicate whether the site is located on Tribal lands, operated by the Indian Health
Service, and/or otherwise affiliated with a Tribe. If not applicable, check “N/A”.
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Lines 51 and 52 are reserved for future use.
G. Block 7: Certifications and Signatures
The Primary Account Holder/Project Coordinator or an authorized designee (see Block 4
instructions) must provide the certifications and signatures in Block 7. All applicable
certifications must be checked, the form must be signed and dated, and Lines 59 – 66
completed to submit this form.
Line 53: Certifies that the signatory is authorized to submit this form on behalf of the
consortium or HCP.
Line 54: Certifies that the information provided in this form and in any attachments is true and
correct.
Line 55: Certifies that if applying as an individual HCP site, the HCP in Block 2 is a non-profit or
public entity and that the site is located in an FCC designated rural area, or is grandfathered rural
pursuant to 47 C.F.R. § 54.600(b)(2).
Line 56: Certifies that if applying as a consortium, the eligible HCPs participating in the
consortium are non-profit or public entities.
Line 57: Certifies that all documentation associated with the Form 460 will be retained for a
period of at least five years. See 47 C.F.R. § 54.648.
Line 58: Requires that if applying as a consortium, the Project Coordinator understands that the
consortium must obtain letters of agency from each consortium member granting the Project
Coordinator the authority to complete, sign, and submit all forms for the funding year(s) for
which support is sought.
Lines 59-66: Require the electronic signature, name, contact information, and employer’s FCC
RN for the person authorized to sign on behalf of the individual HCP or the Consortium Leader.
IV. REMINDERS
•

An applicant must complete the required Form 460(s) and receive an eligibility
determination for each site seeking support and the consortium (if applicable) before the
competitive bidding process may start. If any material information on the approved Form
460 changes, the applicant must submit an updated Form 460 within thirty days of the
change.

•

USAC will not accept incomplete forms. For assistance in completing this form, contact
USAC RHC at 1-800-453-1546 or [email protected].

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