Form 463 RHC HCF Invoice and Request for Disbursement Form

FCC Form 463
Rural Health Care (RHC) Universal Service
Healthcare Connect Fund
Invoice and Request for Disbursement Form

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

Read instructions thoroughly before completing this form. Failure to comply may cause delayed or denied funding.
Block One: General Information
Line 1: RHC Invoice Number

Line 6: Vendor/Applicant Invoice
Number

Line 2: FRN
Line 3: HCP Number

Line 7: SPIN
Line 8: Vendor Name

Line 4: Site/Consortium Name

Line 9: Total Invoice Amount

Line 5: Funding Year:

Block Two: Eligible Expenses
A

B

C

D

E

F

G

H

I

J

K

L

M

N

O

P

Billing Account
Number

HCP Number

Site Name

Category of
Expense

Expense
Type

Bandwidth

Service Start
Date/Shipping
Date or Last
Day of Work

Billing Period
Start Date

Billing Period
End Date

Quantity of
Items Invoiced

Total Cost
Invoiced
(Undiscounted)

Percent of
Expense
Eligible

Percent of
Usage Eligible

Total Eligible
Actual Cost
(Undiscounted)

USF Support
Amount to be
paid

Block Four: Calculation of
Support

FRN ID

Block Three: Dates, Quantities, and Costs

OMB Approved 3060-0804
Estimated time per response: 1 hour
Block Five: Supporting Documentation
Line 10: Applicants and/or vendor may, if they so choose, attach supporting documentation, including, but not limited to, a copy of the bill(s) for the line
item(s) being submitted on this Form 463. By providing copies of the bills and/or supporting documentation, the applicant and vendor will ensure that USAC
has such documentation available for any future audit. See 47 C.F.R. § 54.648
Block Six: Vendor Certifications and Signatures
Line 11: I certify that I am authorized to submit this Form 463 on behalf of the vendor.
Line 12: I understand that the vendor must apply the amount submitted, approved, and paid by USAC (Column P - USF support amount
to be Paid) to the billing account of the health care provider(s) and FRN/FRN IDs listed on this invoice.
Line 13: I declare under penalty of perjury that I have examined this form and attachments to the best of my knowledge, information, and
belief, the dates, quantities, and costs provided under Block three of this Form 463 are true and correct.
Line 14: Signature
Line 15: Date
Line 16: Printed Name of Authorized Person
Line 17: Title/Position of Authorized Person
Line 18: Phone
Ext.
Line 19: Email
Line 20: Employer
Line 21: Employer's FCC RN
Block Seven: Applicant Certifications and Signatures
Line 22: I certify that I am authorized to submit this Form 463 on behalf of the healthcare provider or consortium.
Line 23: I delcare 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 on this Form 463 is true and correct.
Line 24: I declare under penalty of perjury that the HCP or consortium members have received the related services, network equipment,
and/or facilities itemized on this Form 463.
Line 25: I declare under penalty of perjury that the required 35 percent minimum contribution for each item on the Form 463 was funded
by eligible sources as defined in the FCC rules and that the required contribution was remitted to the vendor.
Line 26: Signature
Line 28: Printed Name of Authorized Person
Line 29: Title/Position of Authorized Person
Line 30: Phone
Line 32: Employer

Line 27: Date

Ext.

Line 31: Email
Line 33: Employer's FCC RN

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

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

FCC Form 463 Instructions
Rural Health Care Universal Service
Healthcare Connect Fund
Invoice and Request for Disbursement 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 ....................................................................................................................... 3

D.

Next Steps........................................................................................................................... 3

E.

For More Information.........................................................................................................3

III.

.

SPECIFIC INSTRUCTIONS FOR FILING FORM 463 ....................................................... 3

A.

Block 1: General Information............................................................................................... 3

B.

Block 2: Eligible Expenses .................................................................................................. 4

C.

Block 3: Dates, Quantities, and Costs................................................................................. 5

D.

Block 4: Calculation of Support Amount............................................................................. 5

E.

Block 5: Supporting Documentation ................................................................................... 6

F.

Block 6: Vendor Certifications and Signatures ................................................................... 6

G.

Block 7: Applicant Certifications and Signatures: .............................................................. 6

IV.

REMINDERS...................................................................................................................... 7

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I.

PURPOSE OF FORM

The Federal Communications Commission (FCC) Form 463 is the invoice that serves as the
request to Universal Service Administrative Company (USAC) for the disbursement of funding
from the Healthcare Connect Fund (Fund) for the services, equipment, and/or facilities set forth
in an applicant’s funding commitment letter. The filing of the Form 463 is a joint process
between the applicant (Consortium Leader or HCP, if participating individually) and the vendor
(service provider). The applicant initiates the filing of the Form 463, but the vendor has the
opportunity to review and revise the Form 463 before it is submitted to USAC for processing and
payment. Prior to submission of Form 463, the consortium (or, HCP, if participating individually)
must certify that the form is accurate and that the consortium or HCP has paid its required 35
percent contribution. The vendor must also certify to the accuracy of the form.
If the applicant requested confidential treatment and non-disclosure of commercial and financial
information in Line 32 of the associated FCC Form 462, that request will cover the information
provided in Line 9 (Total Invoice Amount), Column L (Total Cost Invoiced (Undiscounted),
Column O (Total Eligible Actual Cost (Undiscounted)), and Column P (USF Support Amount to
be Paid) of this Form 463.
Applicants must file all forms 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
A. Who Must File
Filing the Form 463 requires the participation of both the vendor (service provider) and the
applicant. To start the filing process, the applicant must first complete the Form 463. The
applicant must also certify to the form’s accuracy and that it has paid its 35 percent required
contribution to the vendor. After the applicant has completed the form and made the required
certifications, it must electronically submit the form to USAC.
Upon receipt of the completed Form 463 from the applicant, USAC will electronically notify the
vendor that the invoice is ready for review. The vendor must then review and certify to the
form’s accuracy and that it has credited the applicant’s account with the amounts listed in
Column U (USF Support Amount to be Paid) on the Form 463 (the portion of total costs to be
supported by the Healthcare Connect Fund for each line item). After the vendor has made its
certifications, it should electronically re-submit the form to USAC. If the vendor makes any
revisions to the Form 463 (including the attachment of any supporting documentation), the
applicant must review and re-certify the form before USAC will begin processing it. See Where
to File below for more details.

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B. When to File
The applicant and vendor should seek to submit a completed Form 463 as soon as possible.
The Form 463 may only be submitted after:
•
•
•

The applicant receives a funding commitment,
The vendor has installed/started/commenced the requested services, network
equipment, and/or facilities, as applicable, and
The applicant has received a bill from the vendor.

The applicant and vendor must file all necessary Form 463(s) within six months after the end date
of the funding commitment, as specified on the funding commitment letter issued by USAC. The
deadline normally will be six months after the end of the funding year unless the funding
commitment is multi-year.
C. Where to File
Applicants and vendors are required to complete and submit the Form 463 online through
USAC’s Rural Health Care (RHC) “My Portal” website at
https://forms.universalservice.org/usaclogin/login.asp. Instructions on how to file electronically
are also 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
Once the Form 463 has been reviewed and approved, the vendor will receive payment either
directly or as an offset to its universal service contribution obligation, depending on which option
the vendor selected on its FCC Form 498.
E. For More Information
Contact the RHC at 1-800-453-1546 between 9:00 a.m. and 6:00 p.m. EST, Monday through
Friday or at [email protected]).
III. SPECIFIC INSTRUCTIONS FOR FILING FORM 463
A. Block 1: General Information
Line 1: The RHC Invoice Number uniquely identifies each Form 463. USAC will generate this
number.
Line 2: Enter the Funding Request Number (FRN) for which this Form 463 is seeking payment.
The FRN is provided in the funding commitment letter. Each funding commitment letter has a
unique FRN.

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The remaining lines in Block 1, except for line 6 (Vendor or Applicant Invoice Number) and line
9 (Total Invoice Amount), will be automatically populated based on the FRN selected. If any of
the automatically populated fields in Block 1 are incorrect, contact RHC (1-800-453-1546, [email protected]) to receive additional information on how to proceed.
Line 3: The HCP Number associated with the FRN. This will be the HCP number of the
Consortium (or HCP, if participating individually).
Line 4: The Consortium or HCP Name associated with the above HCP Number.
Line 5: The Funding Year(s) associated with the FRN entered above.
Line 6 (Optional): Enter the Vendor or Applicant Invoice Number, if desired. This field enables
the vendor and/or applicant to include an identifier to more easily track the Form 463 within the
billing system of the vendor or applicant.
Line 7: The Service Provider Identification Number (SPIN) associated with the FRN entered
above. The SPIN will be included in the funding commitment letter.
Line 8: The Vendor Name associated with the above SPIN. The Vendor Name will be included
in the funding commitment letter.
Line 9: The Total Invoice Amount is the total amount that USAC will pay the vendor for services
listed on this invoice. The total invoice amount is the sum of the values in Column P (USF
Support Amount to be Paid). This value will be automatically calculated based on the values
entered below in Columns I-L.
B. Block 2: Eligible Expenses
Column A – FRN ID: The Funding Request ID (FRN ID) is a separate and unique identifier
associated with each line item for which the applicant is seeking support. The FRN ID for each
line item is found in the funding commitment letter. Select the FRN ID(s) which will be
submitted to USAC for disbursement on this invoice.
Note: An applicant must file a separate Form 463 for each separate funding commitment letter
(FRN). Moreover, an applicant may not enter FRN ID(s) that are not associated with the FRN
entered in Block 1. An applicant may submit a single Form 463 to cover more than one site as
long as the sites and associated expenses (FRN IDs) are part of the same funding commitment
letter.
The remaining columns in Block 2 will be automatically populated based on the FRN and FRN
ID(s) selected. If any of the remaining fields in Block 2 are incorrect, contact RHC (1-800-4531546, [email protected]) to receive additional information on how to proceed.
Column B – Billing Account Number (BAN): If provided on the Form 462, this field will be
automatically populated. If it was not provided on the Form 462, the applicant will enter the
BAN associated with the FRN ID upon the submission of the first invoice for that FRN ID. On
subsequent invoices, the BAN will be pre-populated based on prior submission. The applicant
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typically can find the BAN on the vendor’s bill. Contact the vendor with any questions regarding
the appropriate BAN to enter in this field.
Column C – HCP Number: The HCP number of the site for which this line item is being
submitted.
Column D – Site Name: The name of the site for which this line item is being submitted. The
name must match the name on record for the HCP Number listed for this line item.
Column E – Category of Expense: The Category of Expense associated with the FRN ID.
Column F – Expense Type: The Expense Type associated with the FRN ID.
Column G – Bandwidth: The bandwidth, if applicable, for the line item.
C. Block 3: Dates, Quantities, and Costs
Column H – Service Start Date/Shipping Date or Last Day of Work: Enter the actual date the
broadband service was started, the network equipment was shipped to the customer, or the last
day of work was completed, as applicable.
Column I – Billing Period Start Date: Enter the first date of the billing period for this invoice, if
applicable. If the eligible expense is for a non-recurring expense, enter “N/A.”
Column J – Billing Period End Date: Enter the last date of the billing period for this invoice, if
applicable. If the eligible expense is for a non-recurring expense, enter “N/A.”
Column K – Quantity of Items Invoiced: Enter the quantity of items billed on this invoice. For
example, if applicant is invoicing for two routers, enter “2”. If applicant is invoicing for a single
connection (e.g., circuit), enter “1”.
Column L – Total Actual Cost Invoiced (Undiscounted): Enter the actual total undiscounted
cost for the applicable billing period being submitted for disbursement on this invoice. For
example, if the applicant is invoicing for a single month of recurring service, enter the total actual
cost for the service, including any applicable taxes or surcharges. If the applicant has received
multiple bills from its vendor for the applicable service that it is submitting for disbursement on a
single invoice, calculate the total actual cost, including any applicable taxes and surcharges, for
the applicable line item on each bill and add together to determine the total actual cost for the
billing period.
D. Block 4: Calculation of Support Amount
Column M – Percentage of Expense Eligible: The percentage of expense eligible for support
associated with the FRN ID. This is automatically populated based on the FRN ID selected.
Column N – Percentage of Usage Eligible: The percentage of usage eligible for support
associated with the FRN ID. This is automatically populated based on the FRN ID selected.

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If the percentage in Column M or N is incorrect, contact RHC (1-800-453-1546, [email protected]) to receive additional information on how to proceed.
Column O – Total Eligible Actual Cost (Undiscounted): The total amount of the expense
that is eligible for USF support on this Form 463. The total eligible actual cost is automatically
calculated by multiplying Column L (Total Actual Cost Invoiced (Undiscounted)) by Column M
(Percentage of Expense Eligible) and by Column N (Percentage of Usage Eligible).
Column P – USF Support Amount to be Paid: The total amount that USAC will pay the
vendor for this line item. The “USF Support Amount to be Paid” is capped at the support
amount specified in the funding commitment letter (FCL). First, USAC will multiply Column O
(Total Eligible Actual Cost (Undiscounted)) by the Fund discount percentage, as specified on
the funding commitment letter. The discount percentage is normally 65 percent, but may be
decreased if one or more of the funding caps are reached. See 47 C.F.R. § 54.675.
Second, USAC will pay the lesser of the calculated value and the support amount for the billing
period specified in the FCL. If the calculated value exceeds the funds available for the FRN ID,
the applicant may be able to pursue a reallocation of funds within the FRN. Contact RHC (1800-453-1546, [email protected]) to receive additional information on how to proceed.
E. Block 5: Supporting Documentation
Line 10: Applicants and/or vendors may, if they so choose, attach supporting documentation,
including, but not limited to, a copy of the bill(s) for the line item(s) being submitted on this Form
463. By providing copies of the bills and/or other supporting documentation, the applicant
and/or vendor will ensure that USAC has such documentation for any future audit. See 47
C.F.R. § 54.648.
F. Block 6: Vendor Certifications and Signatures
The vendor representative must provide the certifications and signature in Block 6.
Line 11: Certifies that he or she is authorized to submit the Form 463 on behalf of the vendor.
Line 12: Acknowledges that the vendor must credit the health care provider(s) and FRN/FRN
IDs listed on this invoice with the amount submitted, approved, and paid by USAC (Column P USF support amount to be Paid).
Line 13: Certifies that the dates, quantities, and costs provided under Block 3 of this Form 463
are true and correct.
Lines 14-21: Requires the electronic signature, name, title, contact information, and employer’s
FCC RN for the person authorized to sign on behalf of the vendor.
G. Block 7: Applicant Certifications and Signatures:
Lines 22-25: The representative of the Consortium Leader (or, HCP, if participating
individually) must certify that: (1) he or she is authorized to submit the Form 463 on behalf of the
6

health care provider or consortium, (2) the information provided on the Form 463 is true and
correct, (3) the HCP or consortium members have received the related services, network
equipment, and/or facilities itemized on the Form 463, and (4) the required 35 percent minimum
applicant contribution for each item on the Form 463 was funded by eligible sources as defined
in the FCC rules and that the required contribution has been remitted to the vendor.
Note: For consortium applicants, if the individual participating entities are paying the 35 percent
minimum contribution directly to the vendor, the Consortium Leader must verify that the 35
percent has been paid by the participating entity before certifying and submitting this form.
Lines 26-33: Requires the electronic signature, name, title, contact information, and employer’s
FCC Registration Number (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. .
For an individual HCP, an officer or director of the HCP or other authorized employee of the
HCP must sign the required certifications (a letter of authorization (LOA) must be on record, if
not an employee of the HCP). For a consortium, an officer, director or other authorized
employee of the Consortium Leader must sign the required certifications (an LOA must be on
record, if not an employee of the Consortium Leader).
IV. REMINDERS
•

The applicant and vendor must complete the required Form 463(s) within six months
after the end of the funding commitment. The exact deadline is specified on the funding
commitment letter.

•

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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