FCC Form 462 RHC - Healthcare Connect Fund Program - Description of R

Rural Health Care

Healthcare Connect Fund Program

Description of Request for Funding FCC Form 462

(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	Funding Request Number (FRN)	System Generated	Auto-generated by the system: The system creates a unique identifier for this request.
2	Funding Year	Funding Details	This is the selection of the funding year the applicant is submitting the request for. A funding year runs from July 1 through June 30 of the following year.
3	Site Number	System Generated	Auto-generated by the system: This is the unique identifier assigned by the Universal Service Administrative Company (USAC) to the site listed in Site Name. The Site Number was issued by USAC when the FCC Form 460 was completed.
4	Site Name	System Generated	Auto-generated by the system: This is the name the site submitted on the FCC Form 460.
5	Consortium Number	System Generated	Auto-generated by the system: This is the unique identifier assigned by USAC to the consortium listed in Consortium Name. The Consortium Number was issued by USAC when the FCC Form 460 was completed.
6	Consortium Name	System Generated	Auto-generated by the system: This is the name the consortium submitted on the FCC Form 460.
7	Site Contact Information	System Generated	Auto-generated by the system: This is the site’s physical address, county, city, state, zip code, telephone, website, contact name, contact employer and geolocation the user provided on the FCC Form 460. Geolocation only applies to a site that does not have a street address.
8	Consortium Contact Information	System Generated	Auto-generated by the system: This is the consortium’s address, county, city, state, zip code, telephone, website, contact name, contact employer and geolocation the user provided on the FCC Form 460. Geolocation only applies to a site that does not have a street address.
9	FCC Form 461 Application Number	System Generated	Auto-generated by the system: This is a USAC-assigned unique identifier for the FCC Form 461 associated with this FCC Form 462.
10	Allowable Contract Selection Date (ACSD)	System Generated	Auto-generated by the system: This is the first day in which an applicant may agree to or sign a contract with a vendor. This is calculated based on the number of days the 461 was posted. The ACSD is no less than 29 calendar days after the date on which the FCC Form 461 was posted on USAC’s website.
11	Number of Vendor Bids	Contract Selection	The number of vendors who bid on the request for services in response to the FCC Form 461.
12	498 ID of Selected Vendor	Contract Selection	The selected vendor’s 498 ID (formerly Service Provider Identification Number (SPIN) ID).
13	Selected Vendor Name	Contract Selection	Auto-generated by the system: Based on the 498 ID entered by the user.
14	Service Provider Selection Date	Contract Selection	The date that the vendor was selected for the line item.
15	Continuation with Current Service Provider	Contract Selection	The user selects if the selected vendor is their current service provider.
16	Pricing Confidentiality	Contract Selection	The user indicates if there is a restriction that prevents the pricing information provided by the vendor from becoming public. If so, the applicant must describe the specific restriction and its source.
17	Evergreen Review	Contract Selection Details	The user states that the contract submitted with the funding request shall be reviewed for an evergreen endorsement (thereby allowing a competitive bidding exemption for the life of the contract).
18	Competitive Bidding Exemption	Bidding Details	Only completed if the user is claiming a competitive bidding exemption. If the applicant is claiming the “E-rate Approved Contract” bidding exemption, then the applicant must provide: the E-rate Contract ID (and friendly name), as requested on this FCC Form 462; the E-rate FCC Form 470 number that initiated bidding for that contract; the E-rate contact person for that contract (for quick access); and the contract expiration date.
19	Single, Multiple or Consortium Expense(s)	Expense Request Details	Allows the user to submit single and/or multiple eligible expense items, or Consortium expense items within the request.
20	Site Number	Line Item Details	For multiple expense item requests or Consortium requests, the user can assign site numbers to line items.
21	Site Name	Line Item Details	For multiple expense item requests or Consortium requests, the user can assign site names to line items.
22	Contract ID	Line Item Details	This is the unique identifier assigned by USAC to a contract or service agreement. This identifier helps the user identify the contract in the future.
23	Contract Friendly Name	Line Item Details	This is a unique identifier/nickname created by the user for this request (e.g., Smith Telecommunications Funding Year 2016).
24	Expense Category	Line Item Details	The user selects the expense category of a line item.
25	Expense Type	Line Item Details	The user selects the expense type of a line item.
26	Circuit ID	Line Item Details	The user enters a vendor-specific identifier assigned to the connection between two locations for the line item. The Circuit ID is located on the vendor invoice.
27	Circuit Start Location	Line Item Details	The physical location and/or Site Number where the circuit originates for the line item.
28	Circuit End Location	Line Item Details	The physical location and/or Site Number where the circuit terminates for the line item.
29	Bandwidth	Line Item Details	The user enters the bandwidth for the service.
30	Symmetrical Service	Line Item Details	The user indicates if upload and download speeds are equal for the service.
31	Upload Speed	Line Item Details	The user enters upload speed for the service.
32	Download Speed	Line Item Details	If service is not symmetrical (different upload and download speeds,) then the user enters the download speed for the service.
33	Percentage of Expense Eligible	Line Item Details	The percentage of the line item expense that is eligible for support.
34	Percentage of Usage Eligible	Line Item Details	The percentage of the line item expense that is used by an eligible site.
35	Billing Account Number (BAN)	Line Item Details	The line item BAN listed on the vendor’s bill.
36	Contract Signed Date	Line Item Details	The date the line item contract with the vendor was signed.
37	Initial Contract Length	Line Item Details	The length of the initial contract excluding voluntary options.
38	Number of Contract Extensions	Line Item Details	If the contract includes voluntary options to extend the term of the contract, then the user enters the number of such voluntary options.
39	Duration of each contract extension	Line Item Details	The duration of each contract extension (if applicable)
40	Combined Optional Extension(s) Length	Line Item Details	If the contract includes one or more voluntary options to extend the term of the contract, then the user enters the combined length of all the voluntary options.
41	Expected Service Start Date	Line Item Details	The date service is expected to start.
42	Service Level Agreement (SLA)	Line Item Details	The user indicates whether the applicant’s contract with the vendor includes an SLA.
43	Latency	Line Item Details	The latency requirement per the contract SLA.
44	Jitter	Line Item Details	The jitter requirement per the contract SLA.
45	Packet Loss	Line Item Details	The packet loss rate requirement per the contract SLA.
46	Reliability	Line Item Details	The reliability requirements per the contract SLA.
47	Total Number of Fiber Strands	Line Item Details	The total number of fiber strands that are part of the fiber lease or similar agreement for this line item.
48	Number of Fiber Strands Eligible	Line Item Details	The number of fiber strands that are eligible for support for this line item.
49	Quantity of Items	Line Item Details	The number of items the applicant is seeking under this line item.
50	Processing: Type Funding Request	Line Item Details	The user indicates the type of funding an applicant is requesting (e.g. multi-year, month-to-month, etc.)
51	Expense Frequency	Line Item Details	The user indicates the frequency of the expense for which support is sought.
52	Quantity of Expense Periods	Line Item Details	The user indicates the number of expense periods that are included within this request.
53	Undiscounted Cost Per Expense Period	Line Item Details	The total undiscounted cost per expense period (excluding taxes and fees).
54	New Circuit Installation	Line Item Details	The user indicates if the circuit is newly installed.
55	One-Time Installation Charges	Line Item Details	The user indicates any one-time installation charges.
56	Taxes & Fees Per Expense Period	Line Item Details	The taxes and fees for the line item.
57	Source of Healthcare Provider Contribution	Line Item Details	The sources from which the Site or Consortium will fund its 35 percent contribution for this line item.
58	Total Undiscounted Cost For Eligible (Recurring) Expenses	Expense Request Details	The system will calculate and display the total undiscounted cost for recurring eligible expenses.
59	Total Undiscounted Cost For Eligible (Non-Recurring) Expenses	Expense Request Details	The system will calculate and display the total undiscounted cost for non-recurring eligible expenses.
60	Confidentiality		Optional. The user may request nondisclosure for certain commercial and financial information. See 47 C.F.R. § 0.459(a)(4).
61	Supporting Documentation	Documentation	There is additional documentation required to be submitted (where applicable) with the FCC Form 462 to support the request for funding. Specifically, consortium and individual health care provider (HCP) applicants must submit: contracts, terms of service agreements (if applicable), competitive bidding documents, and written descriptions of cost allocation (if applicable). Consortium applicants must also submit: revisions to financial agreements (if submitted with the FCC Form 460), revisions to the Network Plan (submitted with the FCC Form 461), a network cost worksheet listing all participating HCPs, evidence of a viable source for the 35 percent contribution, sustainability plans (if applicable), revisions to sustainability plans (if previously submitted) and letters of agency (if not previously submitted).
62	I certify under penalty of perjury that I am authorized to submit this request on behalf of the health care provider or consortium.	Certifications	Applicants are required to provide this certification 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 or other authorized employee of the Healthcare Provider. For consortia applicants, an officer, director, or other authorized employee of the Consortium Leader must sign the required certification.
63	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 #62 Purpose/Instructions above.
64	I certify under penalty of perjury that the health care provider or consortium has considered all bids received and selected the most cost-effective method of providing the requested services. The “most cost-effective service” is defined as the “method that costs the least after consideration of the features, quality of transmission, reliability, and other factors that the health care provider deems relevant to choosing a method of providing the required health care services.” 47 C.F.R. § 54.642(c).	Certifications	See Item #62, Purpose/Instructions above.
65	I certify under penalty of perjury that all Healthcare Connect Fund support will be used only for the eligible program purposes for which support is intended.	Certifications	See Item #62, Purpose/Instructions above.
66	I certify that the health care provider or consortium is not requesting support for the same service from both the Telecommunications Program and the Healthcare Connect Fund.	Certifications	See Item #62, Purpose/Instructions above.
67	I certify that the health care provider or consortium satisfies all of the requirements under Section 254 of the Telecommunications Act of 1996, as amended, and applicable Commission rules, and understand that any letter from the Administrator that erroneously commits funds for the benefit of the applicant may be subject to rescission.	Certifications	See Item #62, Purpose/Instructions above.
68	I certify that I have reviewed all applicable rules and requirements for the program and will comply with those rules and requirements.	Certifications	See Item #62, Purpose/Instructions above.
69	I understand that all documentation associated with this application, including all bids, contracts, scoring matrices, and other information associated with the competitive bidding process, and all billing records for services received, 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 #62, Purpose/Instructions above.
70	Signature	Signature	The FCC Form 462 must be certified electronically.
71	Date Submitted	System Generated	Auto generated by system. This date is assigned based on the date the user submits the FCC Form 462.
72	Date Signed	System Generated	Auto generated by system. This date is assigned based on the date the user signs the FCC Form 462.
73	Authorized Person Name	Signature	This is the name of the Authorized Person signing the FCC Form 462.
74	Authorized Person’s Employer	Signature	This is the name of the employer of the Authorized Person signing the FCC Form 462.
75	Authorized Person’s Employer FCC Registration Number	Signature	This is the FCC registration number of the Authorized Person signing the FCC Form 462.
76	Authorized Person’s Title/Position	Signature	This is the title of the Authorized Person signing the FCC Form 462.
77	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 462.
78	Authorized Person Telephone Number	Signature	This is the telephone number of the Authorized Person signing the FCC Form 462.
79	Authorized Person Email Address	Signature	This is the email address of the Authorized Person signing the FCC Form 462.

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