Form 461 RHCP Description of Request for Services

FCC Form 461

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

Rural Health Care (RHC) Universal Service
Healthcare Connect Fund
Request for Services Form
USAC Internal Use Only
FCC Form 461 Application Number:

FCC Form 460 Number:

Posting Start Date:

Posting End Date:

Allowable Contract Selection Date (ACSD):

Form 461 Friendly Name:

Read instructions thoroughly before completing this form. Failure to comply may cause delayed or denied funding.
Block 1: General Information
1 Funding Year

2 HCP Number

3 Site Name/Consortium Name
4 Address Line 1
5 Address Line 2

6 County

7 City
Block 2: Individual HCP Site Request for Services
10

8 State

9 Zip Code

Applicant has prepared and is submitting an RFP with this form.
Applicant has not and will not prepare an RFP.

10a Requested contract period
10b Expected bid evaluation period
11 Number of Days Posted
Number of days USAC should post: ______________

Posting end date: ______________

12 Category of Expense Requested (check all applicable):
Network Equipment
Leased/Tariffed Facilities or Services

12a Identify Anticipated Application(s) and Use(s) of the Supported Connection
The Fund only provides support for costs associated with broadband connectivity. The additional expenses
associated with specific applications (e.g., exchange of electronic health records) are not eligible for support under
the Healthcare Connect Fund.
(Select all that apply. Describe usage level and usage period for all selected.)
Capability
Category: Interactive
Distance learning/training
Real-time remote examination, consultation,
and/or monitoring
Video conferencing
Voice service
Other (describe): _____________
Category: Transactional
Distance learning/training
Electronic patient billing
Exchange of electronic health records
Internet access

Usage Level

Usage Period

Transmission of large files (e.g., X-ray
images, MRI, etc.)
Other (describe): _____________
Category: Bulk
Electronic patient billing
Exchange of electronic health records
Transmission of large files (e.g., X-ray
images, MRI, etc.)
Transmission of store and forward
consultations
Other (describe): _____________
Category: Miscellaneous
Backup/redundant connectivity
Other (describe): _____________
12b Applicant requesting services for an off-site data center:
Yes

No

If yes, provide HCP Number:

12c Applicant requesting services for an off-site administrative office:
Yes
13

No

If yes, provide HCP Number:

Contact for Request for Services:
Same as HCP Physical Location Contact

Same as HCP Primary Account Holder

Other

13a If other, provide full contact information:
Contact Name

Organization Name

Contact Name Title
Phone
Ext.
Block 3: Consortium Request for Services

Email

14 Participating Entities (list all sites, eligible and ineligible, participating in this request for services):
HCP Number:
HCP Number:

HCP Number:
HCP Number:

15 Indicate whether the Consortium plans to utilize an RFP:
Applicant has prepared and is submitting an RFP with this form. If selected, complete 15a.
Applicant has not and will not prepare an RFP.
15a Applicant is submitting an RFP because:
It is seeking more than $100,000 in program support
It is seeking support for infrastructure

Of state, Tribal, or local procurement rules
The applicant has elected to use an RFP

15b Requested contract period
15c Expected bid evaluation period
16 Number of Days Posted:
Number of days USAC should post: ______________

Posting end date: ______________

17 Category of Expense Requested:
Network Design
Network Equipment
Infrastructure/Outside Plant

Leased/Tariffed Facilities or Services
Network Management/Maintenance/Operations Cost (not captured
elsewhere)

17a If requesting only Infrastructure/Outside Plant, enter FCC Form 461 Application Number in which the Consortium
previously requested Leased/Tariffed Facilities or Services.
FCC Form 461 Application Number:
I certify that the prior FCC Form 461 resulted in no responsive bids.

FCC Form 461

18 Description of Services Requested (Required to provide a summary of RFP if submitting one):

19

Contact for Request for Services:
Same as Project Coordinator

Same as Assistant Project Coordinator

Other

19a If other, provide full contact information:
Contact Name

Organization Name

Contact Name Title
Phone
Ext.
Block 4: Declaration of Assistance

Email

20 Have any consultants, service providers, or any other outside experts, whether paid or unpaid, aided in the
preparation of the FCC Forms 460 or 461, RFP, bid evaluation, or network plan?
Yes

No

21 List the contact information for all consultants, service providers, and outside experts that assisted in preparing any
part of the FCC Forms 460, 461, RFP, bid evaluation, or network plan.
a. Name (First, Middle Initial, Last)

b. Organization Type

c. Title/Role

d. Employer

e. Address Line 1
f. Address Line 2
g. City

h. State

i. Zip Code

Block 5: Bid Evaluation
22 Select selection criteria (and weights assigned to each) that will be used to evaluate bids received as a result of this
request for services. Attach supplemental information (if necessary).
Criteria

Weight

a.
b.
c.
Block 6: Additional Documentation
23 List all supporting documentation (RFP, Network Plan, etc) that is required to be submitted with this form.
Type of Documentation
a.
b.
c.
Block 7: Certifications
24

I certify under penalty of perjury that I am authorized to submit this request on behalf of the health care
provider or consortium.

25

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.

26

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

27

I 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 health care
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.

FCC Form 461

Block 7: Certifications
28

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.

29

I certify under penalty of perjury that the applicant has reviewed all applicable requirements for the program
and will comply with those requirements.

30

I understand that all documentation associated with this form, including a copy of the signed 461, any bids/
contracts resulting from the 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.

31 Signature

32 Date

33 Printed Name of Authorized Person
34 Title/Position of Authorized Person
35 Phone
37 Employer

Ext.

36 Email
38 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 461

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

FCC Form 461 Instructions
Rural Health Care (RHC) Universal Service
Healthcare Connect Fund
Request for Services Form
I.

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

II.

FILING REQUIREMENTS AND GENERAL INSTRUCTIONS............................................... 2

A.

Who must file ...................................................................................................................... 2

B.

When to file ......................................................................................................................... 3

C.

Where to file ....................................................................................................................... 4

D.

Next Steps .......................................................................................................................... 4

E.

Modifications to the Form 461 and Associated Documents ................................................ 4

F.

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

III.

..

SPECIFIC INSTRUCTIONS FOR FILING FORM 461 ....................................................... 5

A.

Block 1: General Information.............................................................................................. 5

B.

Block 2: Individual HCP Site Request for Services ............................................................ 5

C.

Block 3: Consortium Request for Services ........................................................................ 7

D.

Block 4: Declaration of Assistance (to be completed by all applicants)............................. 8

E.

Block 5: Bid Evaluation (to be completed by all applicants) ............................................... 8

F.

Block 6: Additional Documentation (to be completed by all applicants) ............................. 9

G. Block 7: Certifications ......................................................................................................... 9
IV.

REMINDERS..................................................................................................................... 10

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I.

PURPOSE OF FORM

Submitting the Federal Communications (FCC) Form 461 is the second step an individual health
care provider (HCP) or consortium must take to participate in the universal service support
mechanism’s Healthcare Connect Fund (Fund). Submitting the Form 460, which enables USAC
to determine whether an HCP site is eligible for support, is the first step.
Unless they are exempt from the competitive bidding requirement (as described below in Who
Must File), all entities participating in the Healthcare Connect Fund must complete the
competitive bidding process before submitting a funding request (the third step, Form 462). To
initiate the competitive bidding process, applicants must submit a request for services (Form
461), which must be posted on USAC’s website for no less than 28 days. The purpose of the
Form 461 and supporting documentation is to provide sufficient information about the requested
services, network equipment, and/or facilities to enable an effective competitive bidding
process, and to provide the Universal Service Administrative Company (USAC) with the required
certifications and other information necessary to prevent waste, fraud, and abuse. Applicants
may seek funding (by filing a Form 462) only after the competitive bidding process is complete.
The required FCC Form 460(s) must be filed prior to or with the filing of the FCC Form 461. An
applicant is encouraged to file its required Form 460(s) at least 30 days prior to filing a request
for services (Form 461). Certain information will carry over (“auto-populate”) from FCC Form
460 to Form 461, so make sure that all of the Form 460(s) for consortia and sites that will be
listed on the Form 461 are up to date before starting Form 461. Applicants are cautioned that
the Form 461 will not be posted on USAC’s site until USAC has confirmed eligibility of the HCP
site(s) for which support is sought. USAC will normally notify each applicant of its eligibility
determination (or whether it needs additional time to process the form) within 30 days of receipt
of the Form 460.
Applicants must complete and submit all forms online with USAC, not the FCC. See Where to
File below for more information.
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
When submitting a completed Form 461, the applicant should include, if applicable, a legal and
financial responsibility agreement (consortium applicant), bid evaluation criteria, request for
proposals (RFP), network plan (consortium applicant), letters of agency (consortium applicant)
and declarations of assistance. Information about the additional documentation is provided in
the specific Block and Line instructions below.
A. Who must file
All applicants are required to file the FCC Form 461 unless their request for services meets one
or more of the competitive bidding exemptions listed below. If an applicant is only exempt for a
portion of the funding year, the applicant must file a Form 461 and go through the competitive
bidding process to receive funding for the remainder of the funding year. If an applicant is

2

unsure as to whether it must file the FCC Form 461, contact RHC at 1-800-453-1546 or [email protected] for assistance.
Competitive bidding exemptions: Certain applicants seeking support from the Fund are exempt
from the competitive bidding process and not required to file a Form 461. After completing the
Form 460 process, exempt applicants may proceed directly to filing the request for funding on
Form 462. Below are the competitive bidding exemptions. See 47 C.F.R. § 54.642(h).
•

Annual Undiscounted Cost of $10,000 or Less: Applicants seeking support for $10,000 or
less of total undiscounted eligible expenses for a single year (i.e. up to $6,500 in Fund
support) are exempt from the competitive bidding requirements. The exemption does
not apply to multi-year contracts. Under this exemption, an applicant is restricted to a
total of $6,500 in annual Fund support for services that are not subject to another
exemption. Services supported through the Telecommunications Program are not
counted toward the $10,000 limit.

•

Government Master Service Agreements (MSAs): Applicants who are purchasing
services and/or network equipment from an MSA negotiated by federal, state, Tribal, or
local government entities on behalf of such HCPs and others, are exempt from the
competitive bidding requirements, but only if such MSAs were awarded pursuant to
applicable federal, state, Tribal, or local competitive bidding requirements. This
exemption only applies to MSAs that were negotiated by, or under the direction of,
government entities and that were subject to government competitive bidding
requirements.

•

MSA Approved under the RHC Pilot Program or Healthcare Connect Fund: Applicants
purchasing services and/or network equipment from MSAs previously approved by
USAC under the RHC Pilot Program or the Healthcare Connect Fund are exempt from
competitive bidding. The exemption is limited to those MSAs that were developed and
negotiated from an RFP or request for services that specifically sought a mechanism to
add additional sites to the network.

•

Evergreen Contracts: Applicants purchasing services from a contract already designated
by USAC as “evergreen” are exempt from the competitive bidding process.

•

E-Rate Approved Contracts: Applicants who enter into consortia with E-rate (Schools
and Libraries Program) participants under 47 C.F.R. § 54.501(c)(1) and are purchasing
services and/or network equipment from a master contract approved under the E-rate
program are exempt from the competitive bidding process.

Applicants who do not meet one or more of the exemptions above are required to complete and
submit this form and associated documents to USAC. Learn more about the competitive
bidding process at: http://www.usac.org/rhc/healthcare-connect/default.aspx.
B. When to file
Applicants may submit the Form 461 starting 180 days before the beginning of the funding year,
which starts on July 1. To allow sufficient time to complete the competitive bidding process,
select a vendor, and have services started on or before the first day of the funding year
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(allowing for a full year of support), applicants should submit this form and all supporting
documentation as soon as possible. Applicants may of course also request funding for less
than a full funding year.
C. Where to file
Applicants must complete and submit all forms online through USAC’s RHC “My Portal” website
at https://forms.universalservice.org/usaclogin/login.asp. Instructions on how to file
electronically may be found at USAC’s RHC website at: http://www.usac.org/rhc/healthcareconnect/default.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.
Do not file this or any other forms for the RHC program with the FCC.
D. Next Steps
After the Form 461 is submitted and processed, USAC will post the Form 461 and supporting
documentation on the RHC website for potential vendors to review and provide bids for the
requested services, network equipment, and/or facilities. After the form is posted, USAC will
send confirmation of the posting to the applicant, including the posting date and the Allowable
Contract Selection Date (ACSD). Unless covered by a competitive bidding exemption, an
applicant must wait at least until its ACSD before it agrees to or signs a contract with a vendor.
An applicant may not agree to or sign a contract with a vendor until after the ACSD, but may
discuss requirements, rates, and conditions with potential vendors prior to that date. Applicants
who sign a service agreement or contract before the ACSD are not eligible for funding.
Applicants may extend the time period for receiving bids beyond the required minimum 28 days
from the posting of the Form 461 without prior approval from USAC. If an applicant would like to
post the Form 461 for longer than 28 days, it must indicate that the posting period is longer than
28 days on the Form 461. An applicant can also decide to extend the bidding period after
USAC has posted the Form 461 by notifying USAC and requesting that USAC update its web
site with notice of the extension. USAC will also revise the ACSD to reflect the extended
bidding period. Once an applicant has extended the bidding period, it cannot be shortened.
E. Modifications to the Form 461 and Associated Documents
All potential bidders must have access to the same information and must be treated in the same
manner. Any additions or modifications to the documents submitted to, and posted by, USAC
must be made available to all potential vendors at the same time and using a uniform method.
This does not prohibit applicants from seeking additional information about particular products
or services during the competitive bidding process, or potential vendors from supplying it. All
applicants who utilize an RFP in conjunction with their competitive bidding process must provide
USAC with any subsequent changes to the RFP. USAC will facilitate this process by allowing
applicants to submit any additions or modifications to USAC, for posting on the same web page
as the originally posted documents. If an applicant makes any changes to its RFP postsubmission, it is responsible for ensuring that USAC has a current version of the RFP for the web
site posting. Any modification or change to the competitive bidding documents will reset the
competitive bidding period and push back the ACSD.

4

F. For More Information
Contact the USAC RHC Help Desk at 1-800-453-1546 between 9:00 a.m. and 6:00 p.m. EST,
Monday through Friday or email at [email protected].
III. SPECIFIC INSTRUCTIONS FOR FILING FORM 461
A. Block 1: General Information
Requires basic applicant information.
Line 1: Enter the funding year for which support is sought. For an applicant that plans to
request a multi-year funding commitment, enter the first funding year for which funding will be
requested. The applicant will use the Form 462 to indicate whether it is requesting a multi-year
funding commitment.
A funding year runs from July 1 to June 30 (thus, funding year 2014 begins on July 1, 2014 and
runs through June 30, 2015).
Line 2: Enter the applicant’s HCP Number, assigned by USAC when the Form 460 is
submitted.
Line 3: The consortium name (or, HCP name, if participating individually) will be autopopulated based on the HCP Number entered in Line 2. If the name is incorrect, the applicant
must submit an updated Form 460.
Lines 4-9: The address, county, city, state and zip code of the consortium (or, HCP, if
participating individually) will also be auto-populated based on the HCP Number entered in Line
2. If any of this information is inaccurate, the applicant must submit an updated Form 460.
B. Block 2: Individual HCP Site Request for Services
Only complete lines 10-13 if applying as an individual HCP site.
Line 10: Requires the applicant to indicate whether it has prepared and is submitting an RFP
with the Form 461. See Additional Documentation in Block 6 below for information about when
an RFP must be submitted. If an applicant makes any changes to its RFP post-submission, it is
responsible for ensuring that USAC has a current version of the RFP for the web site posting.
Line 10a: Enter the requested contract period. An applicant may enter a range of acceptable
contract periods, if so desired. For example, the applicant may request an initial contract period
of 12 to 36 months. If the applicant is only seeking a month-to-month arrangement, please
enter “month-to-month.”
Line 10b: Enter the time period during which the applicant expects to evaluate the bids received
after the end of the posting period.
Note: The expected bid evaluation period is not part of the ACSD calculation. An applicant may
agree to or sign a contract on or after the ACSD, regardless of whether the expected bid
evaluation period has ended, as long as applicant has considered and evaluated all responsive
5

bids to ensure it is conducting a fair and open competitive bidding process. See paragraphs
231-233 and 247-249 of the Healthcare Connect Fund Order for more information.
Line 11: Provide the time period for which the Form 461 package should be posted on USAC’s
web site. Applicant can enter either the number of days (minimum 28 days) or specify an end
date for the posting (must be at least 28 days after USAC posts the applicant’s Form 461
package on the USAC website). USAC’s system will only allow the applicant to enter a date
that meets or exceeds the 28-day minimum requirement.
Line 12: Requires the HCP to select the Category of Expense(s) being requested. The
applicant may select one or both categories. (Note: Sites applying individually may not receive
support for one-time non-recurring charges of more than $5,000. This includes, for example,
reasonable and customary installation charges and network equipment.) For more information
on expense categories, please visit http://www.usac.org/rhc/healthcare-connect/default.aspx.
Line 12a: To assist potential bidders in developing their responses to the Form 461, the
applicant is required to identify the potential applications and uses of the connection for which
support is sought. (Note: The Fund only provides support for costs associated with broadband
connectivity. The additional expenses associated with specific applications (e.g., exchange of
electronic health records) are not eligible for support under the Fund.) Select all that apply
under each of the following categories.
Interactive usage is an interaction that requires the service to have little to no delay.
Example: human-to-human interactions such voice and video conferencing.
Transactional usage is an interaction where minor delays are acceptable, but not above
1-2 seconds. Example: accessing a remote database to enter patient records and billing
information.
Bulk usage is an interaction usually done in the background with lower priority, or in offpeak hours. Example: an automatic, after-hours process to create backup copies of
locally stored files at an off-site location.
Miscellaneous usage is only for capabilities that do not readily fit within the above three
categories. Example: requesting a backup or redundant connection.
For each capability selected, describe the anticipated usage level and usage period.
Usage Level should describe the anticipated level of usage for the selected capability.
Example: for video conferencing, the applicant may want to specify the usage level as “X
simultaneous video calls,” where X is the number of simultaneous video calls that the
connection must support.
Usage Period should describe when and/or how often the selected capability will be
used (e.g., 24x7x365, business hours, after hours, intermittent).
Line 12b-12c: List the HCP number(s) for any off-site data center or off-site administrative for
which support is sought.

6

Lines 13: Identify the primary point of contact for potential vendors. This contact should be
able to provide additional technical details or answer specific questions about the requested
services.
The contact may be (1) the HCP’s physical location contact (the contact listed in Block 2 of Form
460); (2) the HCP’s Primary Account Holder (the contact listed in Block 4 of Form 460), or (3)
“Other.” If you choose one of the first two options, the contact information provided on Form
460 will be carried over to this line. If selecting “other,” provide the required contact information
in Line 13b.
C. Block 3: Consortium Request for Services
Only complete lines 14-19 if applying as a consortium.
Line 14: List the HCP numbers for all sites that are part of this request for services. This
includes all eligible HCP sites, and ineligible sites (including ineligible HCP sites, off-site data
centers, and off-site administrative offices). The applicant will only be able to enter/select sites
that have been associated with the consortium through the consortium’s Form 460 and for which
the Consortium has obtained an LOA giving the Leader the authorization to file a form on
that HCPs behalf. The consortium may include all or a subset of the consortium sites as part of
this request for services.
Lines 15: Indicate whether the consortium has prepared and is submitting an RFP with the
Form 461. See Additional Documentation in Block 6 below for information about when the
submission of an RFP is required. To ensure a fair and open competitive bidding process, all
applicants who utilize an RFP in conjunction with the competitive bidding process are required
to submit the RFP to USAC with their request for services (Form 461).
Line 15a: If the consortium is submitting an RFP with the form, indicate the reason(s) for
submitting an RFP. See instructions for Block 6 below for a list of the circumstances requiring
the use of an RFP.
Line 15b: Enter the requested contract period. An applicant may enter a range of acceptable
contract periods, if so desired. For example, the applicant may request an initial contract period
of 12 to 36 months.
Line 15c: Enter the time period during which the applicant expects to evaluate the bids received
after the end of the posting period.
Note: The expected bid evaluation period is not part of the ACSD calculation. An applicant may
agree to or sign a contract on or after the ACSD, regardless of whether the expected bid
evaluation period has ended, as long as applicant has considered and evaluated all responsive
bids to ensure it is conducting a fair and open competitive bidding process. See paragraphs
231-233 and 247-249 of the Healthcare Connect Fund Order for more information.
Line 16: Provide the time period for which the Form 461 package should be posted on USAC’s
web site. Applicant can enter either the number of days (minimum 28 days) or specify an end
date for the posting (must be at least 28 days after USAC posts the applicant’s Form 461
package on the USAC website). USAC’s system will only allow the applicant to enter a date
that meets or exceeds the 28-day minimum requirement.

7

Line 17: Select the Category of Expense(s) requested. For more information on expense
categories, please visit http://www.usac.org/rhc/healthcare-connect/default.aspx.
Line 17a: If the consortium filing this Form is seeking bids for only “Infrastructure/Outside
Plant,” it is required to certify that it previously posted a Form 461 requesting the proposed
services to be provided over leased/tariffed facilities or services, and the prior Form 461
resulted in no bids. See paragraph 73 of the Healthcare Connect Fund Order. Provide the Form
461 Application Number for the prior posting here.
Line 18: If an RFP is submitted, provide a brief summary of the RFP.
If an RFP is not being submitted, enter sufficient information in Line 18 regarding the desired
services to enable an effective competitive bidding process, including, at a minimum, a summary
of anticipated capabilities for the services being requested as well as usage level and usage
time for each such capability. (See line 12a and associated instructions above.)
Applicants that include a particular vendor’s name, brand, product or service in the description
must also use the words “or equivalent” in the description in order to avoid the appearance that
the applicant has pre-selected the named vendor or intends to give the vendor preference in the
bidding process.
Line 19: Identify the primary point of contact that can provide additional technical details or
answer specific questions from potential vendors about the requested services. Indicate if it is
the Project Coordinator or Assistant Project Coordinator from Block 4 of the Form 460 or “other.”
If “other,” provide the required contact information in Line 19a.
D. Block 4: Declaration of Assistance (to be completed by all applicants)
Line 20: Select whether any consultants, service providers, or any other outside experts,
whether paid or unpaid, aided in the preparation of the Forms 460 or 461, RFP, bid evaluation,
or network plan. An outside expert is anyone who is not an employee of the Consortium
Leader, consortium member, or HCP (if applying individually). An employee of the Consortium
Leader, consortium member, or HCP (if applying individually) may be considered an “outside
expert” if he or she helped prepare the Form 460 or 461 outside of the scope of his or her
employment.
Line 21: If the applicant, selected “yes” in line 20, list the contact information for all consultants,
service providers, and outside experts that assisted in preparing any part of the Forms 460, 461,
RFP, bid evaluation, or network plan. Include the person’s name, title, employer, address, and
organization type (such as consulting firm).
E. Block 5: Bid Evaluation (to be completed by all applicants)
Line 22: List the selection criteria that will be used to demonstrate how the applicant will
choose the most “cost-effective” bid received as a result of this request for services. The
applicant must develop a scoring matrix, or a list of weighted evaluation criteria, that will be
used to evaluate bids. Price must be a primary factor, but need not be the only primary factor.
However, no single factor may receive a weight greater than price. Some examples of other
evaluation criteria include, but are not limited to, bandwidth, quality of transmission, reliability,
previous experience with the service provider, and technical support. The applicant must then
assign weights (with total weight equaling 100%) to the criteria and list both the weights and
8

criteria in Block 5. Any RFP associated with this request for services must also include this list
of weighted evaluation criteria.
F. Block 6: Additional Documentation (to be completed by all applicants)
Line 23: Provide a list of all supporting documentation submitted with this Form 461.
Request for Proposal: Applicants must submit an RFP with its Form 461 if one or more of the
following apply:
• The consortium is seeking more than $100,000 in program support in a funding year.
• The applicant is required to issue an RFP under applicable state, Tribal, or local
procurement rules or regulations.
• The consortium is seeking support for infrastructure (i.e., HCP-owned facilities) as well
as services. Note that applicants seeking support for long-term capital investments,
such as HCP-constructed infrastructure or fiber IRUs, must also seek bids in the same
RFP from vendors who propose to meet those needs via services provided over vendorowned facilities for a time period comparable to the life of the proposed capital
investment.
• The applicant elects to use an RFP in the competitive bidding process.
Example RFPs can be found at http://www.usac.org/rhc/healthcare-connect/default.aspx.
Network Plan: A consortium applicant must submit a narrative of its network plan that includes
the following information:
• Goals and objectives of the proposed network,
• Strategy for aggregating the specific needs of the HCPs (including providers that serve
rural areas) within a state or region,
• Strategy for leveraging existing technology to adopt the most efficient and cost-effective
means of connecting those providers,
• How the broadband services will be used to improve or provide health care delivery,
• Any previous experience in developing and managing health IT (including telemedicine)
programs, and
• A project management plan outlining the consortium’s leadership and management
structure and a work plan, schedule, and budget.
Consortium applicants are required to use program support for the purposes described in their
narrative. An applicant will have the opportunity to amend its narrative, if needed, when it
submits its request for funding commitment.
Letters of Agency: Consortium applications must include or have on file letters of agency
(LOAs) demonstrating that the Consortium Leader is authorized to submit the request for
services (Form 461) on behalf of each HCP listed in Line 14 of this Form 461. See 47 C.F.R. §
54.632(a)(1).
G. Block 7: Certifications (to be completed by all applicants)
Applicant is required to provide certifications in lines 24-37 in order to receive Healthcare
Connect Fund support. For individual HCP applicants, certifications must be signed by an
officer or director of the HCP or other authorized employee of the HCP. For consortium

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applicants, an officer, director, or other authorized employee of the Consortium Leader must
sign the required certification. See 47 C.F.R. § 54.649.
A third-party (e.g., consultant) is prohibited from certifying, signing, or submitting the Form 462,
unless USAC receives, prior to the submission of the form, 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. If not
previously provided to USAC, submit any such required letter of authorization to USAC and
obtain USAC approval before signing and submitting this form.
Line 24: Certifies that applicant’s representative is authorized to submit this form on behalf of
the consortium or HCP.
Line 25: Certifies that the information provided in this form and in any attachments is true and
correct.
Line 26: Certifies that applicant has followed applicable state, Tribal, or local procurement
rules.
Line 27: Certifies that applicant will only use Healthcare Connect Fund support for purposes
reasonably related to the provision of healthcare service or instruction that the HCP is legally
authorized to provide under the law of the state in which the services are provided. In addition,
the applicant certifies 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.
Line 28: Certifies that the applicant satisfies all of the requirements under Section 254 of the
Act and applicable Commission rules.
Line 29: Certifies that applicant has reviewed all program requirements and will comply with
those requirements.
Line 30: Certifies that all documentation associated with the form will be retained for a period of
at least five years pursuant to 47 C.F.R. § 54.648. Documentation includes all bids, contracts,
scoring matrices, and other information associated with the competitive bidding process, and all
billing records for services received.
Lines 31-38: Requires 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. The name, contact information, and employer’s FCC RN will be auto populated based
on who is logged in and completing this form.
IV. REMINDERS
•

This Form 461 must be submitted and the competitive bidding process completed before
USAC may provide support for the requested services, network equipment, and/or
infrastructure.

•

Incomplete forms or forms missing required documentation will not be processed. For
assistance in completing this form, contact USAC RHC at 1-800-453-1546 or [email protected].
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