FCC Form 461 RHC - Healthcare Connect Fund Program - Description of R

Rural Health Care

Healthcare Connect Fund Program

Description of Request for Services FCC Form 461

(Note: This is a representative description of the information to be collected via the online portal and is not intended to be a visual representation of what each applicant will see, the order in which they will see information, or the exact wording or directions used to collect the information. Where possible, information already provided by applicants from previous filing years or that was pre-filed in the system portal will be carried forward and auto-populated into the form.)

Item #	Field Description	Category	Purpose/Instructions
1	Applicant’s FCC Form Nickname	Request For Proposal (RFP) Details	Optional. To create a unique identifier for this request, the user simply enters a nickname (e.g., 2016 Funding Year Homewood FCC Form 461).
2	Funding Year	RFP Details	This is the selection of the funding year the applicant is submitting the request for.
3	FCC Form 461 Application Number	System Generated	Auto-generated by the system: This is a Universal Service Administrative Company (USAC)-assigned unique identifier for this request.
4	FCC Form 460 Number	System Generated	Auto-generated by the system: Based on information for the previously submitted FCC Form 460.This is a USAC-assigned unique identifier for this request.
5	FCC Form 461 Posting Start Date	System Generated	Auto-generated by the system: This is a USAC-assigned date based on the date of submission of the request and review of the request.
6	FCC Form 461 Posting End Date	System Generated	Auto-generated by the system: This is a USAC-assigned date based on no less than 28 days from the FCC Form 461 posting start date.
7	Allowable Contract Selection Date (ACSD)	System Generated	Auto-generated by the system: This is a USAC-assigned date, plus any time added by the user, after which the applicant is able to enter into an agreement with a service provider. This date must be a date after the RFP and/or FCC Form 461 posting end date.
8	Site Name	System Generated	Auto-populated by the system: This is the name the site submitted on the FCC Form 460.
9	Site Number	System Generated	Auto-populated by the system: This is the unique identifier assigned by USAC to the site listed in Site Name on the FCC Form 460.
10	Site Address	System Generated	Auto-populated by the system: This is the site’s physical address, county, city, state, zip code and geolocation the user submitted on its FCC Form 460. Geolocation only applies to a site that does not have a street address.
11	Consortium Name	System Generated	Auto-populated by the system: This is the name the consortium submitted on the FCC Form 460.
12	Consortium Number	System Generated	Auto-populated by the system: This is the unique identifier assigned by USAC to the consortium listed in Site Name on the FCC Form 460.
13	Consortium Address	System Generated	Auto-populated by the system: This is the consortium’s address, county, city, state, zip code and geolocation the user submitted on its FCC Form 460. Geolocation only applies to a consortium that does not have a street address.
14	FCC Registration Number	System Generated	Auto-populated by the system: This is either the consortium or the site’s unique FCC registration number submitted via the FCC Form 460
15	Indicate Whether a Separate Request for Proposal (RFP) will be Released for this Request	RFP Details	The user indicates whether they are using an RFP. If an RFP is used, it must be attached to the FCC Form 461 so that it can be “released” with the posting of the FCC Form 461.
16	Letter of Agency (LOA)	RFP Details	For consortia only. The Consortium Leader is required to submit an LOA for each eligible health care provider participating in the consortium no later than when it submits its request for services (FCC Form 461).
17	Network Plan	RFP Details	For consortia only. If an applicant is a consortium, they must submit a narrative of its Network Plan with the FCC Form 461.
18	Needs or Services Requested: Category	RFP Details	The user details which category(s) of services/activities it is requesting.
19	Needs or Services Requested: Service/Activity Details	RFP Details	The user details any services/activities sought with the request.
20	Needs or Services Requested: Applications & Usage	RFP Details	The user details the usage level and usage period for services/activities requested.
21	Needs or Services Requested: Site(s) Listing	RFP Details	The user provides information on the sites/entities included in the request.
22	Needs or Services Requested: Desired Contract Length	RFP Details	The user provides details on the length and type of contract requested.
23	Needs or Services Requested: Bid Evaluation Period	RFP Details	Optional. The user can expresses how long after the end of the FCC Form 461 28-day posting period they will need to evaluate bids. The expected bid evaluation period is not part of the ACSD calculation.
24	Needs or Services Requested: USAC Bid Posting Period	RFP Details	Optional. The user may add days to the posting period beyond the required minimum 28-day posting period. The system will only allow the applicant to enter a date that meets or exceeds the 28-day minimum requirement.
25	Bidding Evaluation	RFP Details	The user develops a weighted evaluation criteria (e.g., scoring matrix) that demonstrates how the applicant will choose the most ‘cost-effective' bid before submitting a request for services. Price must be a primary factor, but need not be the only primary factor. A non-price factor can receive an equal weight to price, but may not receive a greater weight than price.
26	Supporting Documentation	Documentation	Optional. Provides an option for the user to upload and submit supporting documents to support their request.
27	Contact Person Name	RFP Details	The user must provide the name of the person who should be contacted with questions about this request. This could be the Primary Contact, Additional Contact(s) or another person qualified to answer questions relating to the request.
28	Contact Person Employer	RFP Details	The user must provide the employer of the person who should be contacted with questions about this request.
29	Contact Person Title	RFP Details	The user must provide the title of the person who should be contacted with questions about this request.
30	Contact Person Mailing Address	RFP Details	The user must provide the mailing address of the person who should be contacted with questions about this request.
31	Contact Person Telephone Number	RFP Details	The user must provide the telephone number of the person who should be contacted with questions about this request.
32	Contact Person Email Address	RFP Details	The user must provide the email address of the person who should be contacted with questions about this request.
33	Contact Person Fax Number	RFP Details	The user must provide the fax number of the person who should be contacted with questions about this request.
34	Declaration of Assistance	RFP Details	If user uses a consultant, service provider, or any other outside expert, whether paid or unpaid, to submit its request, the user must provide the name of the company, name of the person representing the applicant, title of the person representing the applicant, telephone number, email address, and physical address.
35	I certify under penalty of perjury that I am authorized to submit this request on behalf of the Healthcare Provider or consortium.	Certifications	The applicant is required to provide certifications in order to receive Healthcare Connect Fund support. For individual healthcare provider applicants, certifications must be signed by an officer or director of the healthcare provider. For consortium applicants, an officer, director, or other authorized employee of the Consortium Leader must sign the required certification.
36	I declare under penalty of perjury that I have examined this request and attachments and to the best of my knowledge, information, and belief, all information contained in this request and in any attachments is true and correct.	Certifications	See Item #35 Purpose/Instructions above.
37	I certify under penalty of perjury that the applicant has followed any applicable state, Tribal, or local procurement rules.	Certifications	See Item #35 Purpose/Instructions above.
38	If 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 Healthcare 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.	Certifications	See Item #35 Purpose/Instructions above.
39	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.	Certifications	See Item #35 Purpose/Instructions above.
40	I certify under penalty of perjury that the applicant has reviewed all applicable requirements for the program and will comply with those requirements.	Certifications	See Item #35 Purpose/Instructions above.
41	I understand that all documentation associated with this request, including a copy of the signed FCC Form 461, any bids/contracts resulting from the FCC Form 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.	Certifications	See Item #35 Purpose/Instructions above.
42	Signature	Signature	The FCC Form 461 must be signed electronically.
43	Date Submitted	System Generated	Auto generated by system.
44	Date Signed	System Generated	Auto generated by system.
45	Authorized Person Name	Signature	This is the name of the Authorized Person signing the FCC Form 461.
46	Authorized Person’s Employer	Signature	This is the name of the employer of the Authorized Person signing the FCC Form 461.
47	Authorized Person’s Employer FCC Registration Number	Signature	This is the FCC registration number of the Authorized Person signing the FCC Form 461.
48	Authorized Person’s Title/Position	Signature	This is the title of the Authorized Person signing the FCC Form 461.
49	Authorized Person’s Mailing Address	Signature	This is the address (can be physical address or mailing address) of the Authorized Person signing the FCC Form 461.
50	Authorized Person Telephone Number	Signature	This is the telephone number of the Authorized Person signing the FCC Form 461.
51	Authorized Person Email Address	Signature	This is the email address of the Authorized Person signing the FCC Form 461.

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