FCC Form 465 RHC - Telecommunications Program - Description of Eligib

Rural Health Care

Telecommunications Program

Description of Eligibility and Request for Services FCC Form 465

(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 will be carried forward and auto-populated into the form.)

Item #	Field Description	Category	Purpose/Instructions
1	FCC Form 465 Application Number	System Generated	Auto generated by system. This is a Universal Service Administrative Company (USAC)-assigned unique identifier for this request.
2	Applicant’s FCC Form Nickname	Request Information	Optional. To create a unique identifier for this submission, the user simply enters a nickname (e.g., Funding Year (FY) 2016 Homewood FCC Form 465).
3	Site Name	Site Information	This is the name of the site.
4	Site Number	Site Information	Auto generated by system. This is the unique identifier assigned by USAC to the site listed in Site Name.
5	Site Address	Site Information	This is the site’s physical address, county, city, state, zip code and geolocation. Geolocation is an optional field that is only required for a site that does not have a street address.
6	Site Website	Site Information	Optional. The website address of the site.
7	Site FCC Registration Number (FCC RN)	Site Information	This is the site’s unique FCC RN identifier.
8	Employer Identification Number (EIN)	Site Information	The EIN is also known as a Federal Tax Identification Number, and is used to identify a business or non-profit entity.
9	National Provider Identifier (NPI)	Site Information	The ten-digit health care facility NPI is used on Medicare and Medicaid claims.
10	Organization Taxonomy Code	Site Information	This is the ten-digit Health Care Provider (HCP) Taxonomy Code that corresponds to the NPI.
11	Site Taxonomy Code	Site Information	Optional. Should the Organization Taxonomy Code not adequately describe the site, the user may add additional Taxonomy Codes.
12	Legal Entity Name	Site Information	If applicable. This is the name of the Legal Entity that owns and/or operates the site. In some cases, the Legal Entity Name will be different from the Site Name.
13	Legal Entity FCC RN	Site Information	If applicable. This is the unique FCC identifier for the Legal Entity that owns and/or operates the site.
14	Legal Entity Contact	Site Information	This is the Legal Entity’s physical address, county, city, state, zip code, telephone, website, contact name, email, phone number, contact employer and geolocation. Geolocation only applies to a site that does not have a street address.
15	Organization Affiliation	Site Information	If applicable. User identifies as being a member of a larger collective group (e.g. consortium, association, network, etc.) that participates in either the Telecommunications or Healthcare Connect Fund Programs.
16	Funding Year	RFP Details	This is the selection of the FY the applicant is submitting the request for. Funding years run from July 1 through June 30 of the following year. Available funding year selections will be displayed by the system.
17	Eligibility Entity Type that Requests Support	Site Information	These are the eligible health care provider categories as provided in 47 C.F.R. §54.600(a): Post-secondary educational institution offering health care instruction, teaching hospital or medical school; Community health center or health center providing health care to migrants; Local health department or agency; Community mental health center; Not-for-profit hospital; Rural health clinic; Skilled nursing facility; Dedicated ER of rural, for-profit hospital; Part-time eligible entity; Consortium of the above.
18	Eligibility Entity Type Requests Support: If Consortium, Dedicated Emergency Department or Part-Time Eligible Entity	Site Information	The user further describes the site if they qualify as one of these types of sites.
19	Eligibility Entity Type that Seek Support: If Community Mental Health Center	Site Information	If the user chooses “Community Mental Health Center,” then the user must submit a Community Mental Health Center Certification, a copy of the health care provider’s (HCP) operating license
20	Eligibility Entity Type Requests Support: Additional Site Information	Site Information	Optional. The user has the ability to provide a brief explanation of why the site qualifies as the category selected.
21	Eligibility Entity Type that Seek Support: Additional Site Information	Site Information	If applicable, the user indicates if the site is located on Tribal lands, operated by the Indian Health Service, and/or otherwise affiliated with a Tribe.
22	Needs or Services Requested: Category	RFP Details	The user details which category(s) of services/activities the site is requesting.
23	Needs or Services Requested: Service/Activity Details	RFP Details	The user details any services/activities sought with the request, (e.g. how the services/activities will be used or usage level and usage period). This allows service providers to learn what the site wants to do, so they can propose services to meet the site’s needs.
24	Needs or Services Requested: Desired Contract Length	RFP Details	The user provides details on the length and type of contract requested.
25	Needs or Services Requested: Bid Posting Period	RFP Details	Optional. The user may add days on to the posting period beyond the required minimum 28-day posting period.
26	Bidding Evaluation	RFP Details	The user develops and enters 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. The applicant shall certify to USAC that the selected provider is the most cost-effective method of providing the requested service or services, where the most cost-effective method of providing a service is defined as the method that costs the least after consideration of the features, quality of transmission, reliability, and other factors that the applicant deems relevant to choosing a method of providing the required health care services. See 47 C.F.R. sec. 54.603(b)(4).
27	Primary Contact Name	Contact Information	This is the name of the person who should be contacted with questions about this request. This person must be employed by the Legal Entity listed on this form.
28	Primary Contact Employer/Organization	Contact Information	This will auto-populate to be the information listed within “Legal Entity Name.”
29	Primary Contact Title	Contact Information	This is the title of the person who should be contacted with questions about this request.
30	Primary Contact Mailing Address	Contact Information	This is the mailing address, county, city, state, and zip code of the person who should be contacted with questions about this request.
31	Primary Contact Telephone Number	Contact Information	This is the telephone number of the person who should be contacted with questions about this request.
32	Primary Contact Email Address	Contact Information	This is the email address of the person who should be contacted with questions about this request.
33	Primary Contact Fax Number	Contact Information	This is the fax number of the person who should be contacted with questions about this request.
34	Additional Contact(s)	Contact Information	Allows the user to add additional contact person(s) to the request. To add an additional contact person, the user must provide the contact’s name, employer, mailing address, county, city, state, zip code, telephone number, email address and website (optional). This person will be an account holder in MyPortal with access to the site’s application forms.
35	Supporting Documentation	Documentation	Optional. This provides an option for the user to upload and submit documents to support their request.
36	I certify that I am authorized to submit this request on behalf of the above-named entity, that I have examined this request, and that to the best of my knowledge, information, and belief, all statements of fact contained herein are true.	Certifications	This certification is required in order to submit the request for discounted services.
37	I certify that the health care provider (HCP) has followed any applicable State or local procurement rules.	Certifications	See Item #36, Purpose/Instructions.
38	I certify that the telecommunications services that the HCP receives at reduced rates as a result of the HCPs’ participation in this program, pursuant to 47. U.S.C. § 254 as implemented by the Federal Communications Commission, will be used solely for purposes reasonably related to the provision of health care service or instruction that the HCP is legally authorized to provide under the law of the state in which the services are provided and will not be sold, resold, or transferred in consideration for money or any other thing of value.	Certifications	See Item #36, Purpose/Instructions.
39	I certify that the health care provider (HCP) is a non-profit or public entity.	Certifications	See Item #36, Purpose/Instructions.
40	I certify that the health care provider (HCP) is located in a rural area. Visit the Eligible Rural Areas Search Tool on the Telecommunications Program web page at http://usac.org/rhc/telecommunications/tools/rural/search/search.asp or contact RHC at (800) 453-1546 for a listing of rural areas.	Certifications	See Item #36, Purpose/Instructions.
41	Pursuant to 47 C.F.R. § 54.601 and 54.603, I certify that the HCP that I am representing satisfies all of the requirements herein and will abide by all of the relevant requirements, including all applicable FCC rules, with respect to funding provided under 47 U.S.C. § 254.	Certifications	See Item #36, Purpose/Instructions.
42	Signature	Signature	The FCC Form 465 must be certified electronically.
43	Date Submitted	System Generated	Auto generated by system.
44	Date Signed	System Generated	Auto generated by system.
45	Authorized Person	Signature	This is the name of the Authorized Person signing the FCC Form 465. This field will be auto-populated if already within the system
46	Authorized Person’s Employer	Signature	This is the name of the employer of the Authorized Person signing the FCC Form 465. This field will be auto-populated if already within the system
47	Authorized Person’s Employer FCC RN	Signature	This is the FCC RN of the Authorized Person signing the FCC Form 465. This field will be auto-populated if already within the system
48	Authorized Person’s Title/Position	Signature	This is the title of the Authorized Person signing the FCC Form 465. This field will be auto-populated if already within the system
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 465. This field will be auto-populated if already within the system
50	Authorized Person Telephone Number	Signature	This is the telephone number of the Authorized Person signing the FCC Form 465. This field will be auto-populated if already within the system
51	Authorized Person Email Address	Signature	This is the email address of the Authorized Person signing the FCC Form 465. This field will be auto-populated if already within the system
52	Declaration of Assistance	Request Information	If applicable. 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.
53	Third Party Authorization (TPA)	Request Information	If applicable, the user must provide a TPA which provides written authorization to a third party/consultant to complete and submit FCC Forms on behalf of the HCP for the Telecommunications Program.

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