FCC Form 463 RHC - Healthcare Connect Fund Program - Description of R

Rural Health Care

Healthcare Connect Fund Program

Description of Request for Funding Disbursement FCC Form 463

(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-generated into the form.)

Item #	Field Description	Category	Purpose/Instructions
1	Rural Health Care Invoice Number	Request Information	Auto-generated by the system: This is the unique identifier for the FCC Form 463.
2	Funding Request Number (FRN)	Request Information	Auto-generated by the system: This is a unique identifier auto-generated by the system on the FCC Form 462 and provided in the funding commitment letter to the applicant.
3	Funding Year: Funding Start Date	Request Information	Auto-generated by the system: This displays the date funding began for this Funding Request Number (FRN). Taken from information provided on the FCC Form 462. Funding years start on July 1 of each year and end on June 30 of the following year.
4	Funding Year: Funding End Date	Request Information	Auto-generated by the system: This displays the date funding will end/ended for this FRN. Taken from information provided on the FCC Form 462.
5	Site Number	Request Information	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.
6	Site Name	Request Information	Auto-generated by the system: This is the name the site submitted on the FCC Form 460.
7	Consortium Number	Request Information	Auto-generated by the system: This is the unique identifier assigned by USAC to the consortium listed in Site Name. The Consortium Number was issued by USAC when the FCC Form 460 was completed.
8	Consortium Name	Request Information	Auto-generated by the system: This is the name the consortium submitted on the FCC Form 460.
9	Site Contact Information	Request Information	Auto-generated by the system: This is the site’s physical address, county, city, state, zip code, telephone, website, and geolocation the user provided on the FCC Form 460. Geolocation only applies to a site that does not have a street address.
10	Consortium Contact Information	Request Information	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.
11	498 ID of Service Provider	Request Information	Auto-generated by the system: The selected service provider’s 498 ID (formerly Service Provider Identification Number (SPIN) ID). The 498 ID is pulled from the FCC Form 462 for an FRN.
12	Service Provider Name	Request Information	Auto-generated by the system: Based on the 498 ID entered by the user and pulled from the FCC Form 462 for the FRN.
13	Service Provider/Applicant Invoice Number	Request Information	Optional. Allows the vendor and/or applicant to track their FCC Form 462 within their billing system.
14	Funding Request Number Identification Number (FRN ID)	Line Item Details	Auto-generated by the system: Building upon the FRN, the system auto-generates an FRN ID to correspond to an individual line item.
15	Site Number: Line Item Details	Line Item Details	Auto-generated by the system: Based on the line item’s FRN ID.
16	Site Name: Line Item Details	Line Item Details	Auto-generated by the system: Based on the line item’s FRN ID.
17	Expense Category	Line Item Details	Auto-generated by the system: Based on the line item’s FRN ID.
18	Expense Type	Line Item Details	Auto-generated by the system: Based on the line item’s FRN ID.
19	Bandwidth	Line Item Details	Auto-generated by the system: Based on the line item’s FRN ID.
20	Service Start Date	Line Item Details	The date service is expected to start for the line item.
21	Quantity of Items	Line Item Details	The number of items the applicant is seeking under the line item.
22	Billing Account Number (BAN)	Line Item Details	The line item BAN is listed on the service provider’s bill.
23	Billing Period Start Date	Line Item Details	The first date of the billing period for the invoice.
24	Billing Period End Date	Line Item Details	The last date of the billing period for the invoice.
25	Billing Period Eligible Amount	Line Item Details	Auto-generated by the system: The amount an applicant is eligible to receive for the billing period. This is derived from information supplied on the FCC Form 462.
26	Total Actual Undiscounted Cost	Line Item Details	The actual total undiscounted cost (including taxes and fees) for the billing period.
27	Percentage of Expense Eligible	Line Item Details	Auto-generated by the system: The percentage of the line item expense that is eligible for support. Taken from information provided on the FCC Form 462.
28	Percentage of Usage Eligible	Line Item Details	Auto-generated by the system: The percentage of the line item expense that is used by an eligible site. Taken from information provided on the FCC Form 462.
29	Total Eligible Actual Cost	Line Item Details	Auto-generated by the system: The system will calculate and display the total amount of the line item expense that is eligible for universal service fund (USF) support. Taken from information provided on the FCC Form 462.
30	USF Support To Be Paid	Line Item Details	The system will calculate and display the total amount of the line item expense that USAC will pay the service provider for the line item.
31	Supporting Documentation	Documentation	Optional. Provides the option for the user to upload and submit documents to support their request.
32	I certify under penalty of perjury that I am authorized to submit this request on behalf of the service provider.	Service provider Certifications	The service provider’s representative must make this certification.
33	I understand that the service provider must apply the amount submitted, approved, and paid by USAC to the billing account of the health care provider(s) and FRN/FRN ID listed on this invoice.	Service provider Certifications	See Item # 32, Purpose/Instructions.
34	I declare under penalty of perjury that I have examined this form and attachments to the best of my knowledge, information, and belief, the date, quantities, and costs provided are true and correct.	Service provider Certifications	See Item # 32, Purpose/Instructions.
35	Signature	Service provider Signature	The FCC Form 463 must be certified electronically by the service provider.
36	Date Submitted	System Generated	Auto generated by system.
37	Date Signed	System Generated	Auto generated by system.
38	Authorized Person Name	Service provider Signature	This is the name of the Authorized Person signing the FCC Form 463 on behalf of the service provider.
39	Authorized Person’s Employer	Service provider Signature	This is the name of the employer of the Authorized Person signing the FCC Form 463 on behalf of the service provider.
40	Authorized Person’s Employer FCC RN	Service provider Signature	This is the FCC RN of the Authorized Person signing the FCC Form 463 on behalf of the service provider.
41	Authorized Person’s Title/Position	Service provider Signature	This is the title of the Authorized Person signing the FCC Form 463 on behalf of the service provider.
42	Authorized Person’s Mailing Address	Service provider Signature	This is the address (can be physical address or mailing address) of the Authorized Person signing the FCC Form 463 on behalf of the service provider.
43	Authorized Person Telephone Number	Service provider Signature	This is the telephone number of the Authorized Person signing the FCC Form 463 on behalf of the service provider.
44	Authorized Person Email Address	Service provider Signature	This is the email address of the Authorized Person signing the FCC Form 463 on behalf of the service provider.
45	I certify under penalty of perjury that I am authorized to submit this request on behalf of the healthcare provider or consortium.	Applicant Certifications	The authorized representative of the Consortium Leader (or, Healthcare Provider, if participating individually) must make this certification.
46	I declare under penalty of perjury that I have examined this form and attachments to the best of my knowledge, information, and belief, the date, quantities, and costs provided are true and correct.	Applicant Certifications	The authorized representative of the Consortium Leader (or, Healthcare Provider, if participating individually) must make this certification.
47	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.	Applicant Certifications	See Item # 46, Purpose/Instructions.
48	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 service provider.	Applicant Certifications	See Item # 46, Purpose/Instructions.
49	Signature	Applicant Signature	The FCC Form 463 must be certified electronically by the applicant.
50	Date Submitted	System Generated	Auto generated by system.
51	Date Signed	System Generated	Auto generated by system.
52	Authorized Person Name	Applicant Signature	This is the name of the Authorized Person signing the FCC Form 463 on behalf of the applicant.
53	Authorized Person’s Employer	Applicant Signature	This is the name of the employer of the Authorized Person signing the FCC Form 463 on behalf of the applicant.
54	Authorized Person’s Employer FCC RN	Applicant Signature	This is the FCC RN of the Authorized Person signing the FCC Form 463 on behalf of the applicant.
55	Authorized Person’s Title/Position	Applicant Signature	This is the title of the Authorized Person signing the FCC Form 463 on behalf of the applicant.
56	Authorized Person’s Mailing Address	Applicant Signature	This is the address (can be physical address or mailing address) of the Authorized Person signing the FCC Form 463 on behalf of the applicant.
57	Authorized Person Telephone Number	Applicant Signature	This is the telephone number of the Authorized Person signing the FCC Form 463 on behalf of the applicant.
58	Authorized Person Email Address	Applicant Signature	This is the email address of the Authorized Person signing the FCC Form 463 on behalf of the applicant.

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