FCC Form 466 RHC - Telecommunications Program - Description of Reques

Rural Health Care

Telecommunications Program

Description of Request for Funding FCC Form 466

(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 Year	Funding Details	This is the selection of the funding year (FY) associated with the FCC Form 465 submitted. Depending on the timing of the request, multiple fund years may be available for the user to select.
2	FCC Form 466 Application Number	System Populated	Auto-populated by the system: This is a USAC-assigned unique identifier for this request.
3	Site Number	System Populated	Auto-populated by the system: This is the unique identifier assigned by the Universal Service Administrative Company (USAC) to the site listed in Site Name. This number was issued by USAC when the FCC Form 465 was completed.
4	Site Name	System Populated	Auto-populated by the system: This is the name of the site submitted on the FCC Form 465.
5	Site Contact Information	System Populated	Auto-populated by the system: This is the site’s physical address, county, city, state, zip code, telephone, website, contact name, contact employer, email address and geolocation. Geolocation only applies to a site that does not have a street address. This information was previously submitted on the FCC Form 465.
6	FCC Form 465 Application Number	System Populated	Auto-populated by the system: This is a USAC-assigned unique identifier for this request. This number was previously assigned on the FCC Form 465.
7	Legal Entity Name	Site Information	Auto-populated by the system: 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. This is the name previously submitted on the FCC Form 465.
8	Legal Entity FCC RN (FCC RN)	Site Information	Auto-populated by the system: If applicable. This is the unique FCC identifier for the legal entity that owns and/or operates the site. This identifier was previously submitted on the FCC Form 465.
9	Legal Entity Contact	Site Information	Auto-populated by the system: 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. This previously supplied when the user completed the FCC Form 465.
10	Billed Entity Name	Bill Payer Information	If applicable. This is the entity that pays the bills of the service provider for the site. This may be the site itself, or it may be the “parent” organization, association, consortium, etc. to which the site belongs.
11	Billed Entity Contact Information	Bill Payer Information	If applicable. This is the Billed Entity’s physical address, county, city, state, zip code, telephone, website, contact name, contact employer, email address and geolocation.
12	Billed Entity FCC Registration Number (FCC RN)	Bill Payer Information	Auto-populated by the system: This is the unique FCC identifier for the Legal Entity. This number was previously supplied when the user completed the FCC Form 465.
13	Allowable Contract Selection Date (ACSD)	System Populated	Auto-populated by the system: This is a USAC-assigned date (at least 28 days after the description set forth in the HCP’s Form 465 is posted on the RHC website). This date expresses the earliest date (ACSD) on which the HCP may sign an agreement or otherwise select a carrier to provide services to the HCP.
14	Number of Service Provider Bids	Contract Selection Details	The number of service providers who bid on the request for services in response to the FCC Form 465.
15	Multiple Sites	Funding Details	If applicable. If the HCP is a mobile rural health care provider, it must list the names, full addresses, expected schedule, duration of visits to all sites to be served, and number of patients served at each location by the mobile HCP during the funding year. The HCP must verify that each of the sites is rural, or prorate the support request to cover only the time when the mobile health care provider will operate in the rural area.
16	498 ID of Selected Service Provider(s)	Funding Details	The selected Service Provider’s 498 ID (formerly the Service Provider Identification Number (SPIN)). There may be multiple service providers should the circuit have multiple connections.
17	Selected Service Provider Name(s)	Funding Details	Auto-populated by the system: This name is based on the 498 ID entered by the user. There may be multiple service providers should the circuit have multiple connections.
18	Selected Service Provider Contact	Funding Details	Auto-populated by the system: This contact information is based on the 498 ID entered. This is the service provider’s physical address, county, city, state, zip code, telephone, website, contact name, email, phone number, contact employer and geolocation. There may be multiple service providers should the circuit have multiple connections.
19	Service Provider Selection Date	Funding Details	The date that the line item service provider was selected. The HCP or its authorized representative must not select a service provider or enter into a contract or purchase an agreement with a service provider until at least 28 days have elapsed since the Form 465 was posted on the RHC website.
20	Continuation with Current Service Provider	Funding Details	The user indicates if the selected service provider is its current service provider.
21	Contract ID	Funding Details	The unique identifier assigned by USAC to a contract or service agreement. This identifier helps the applicant identify the contract in the future and apply in subsequent funding years.
22	Contract Reference Number	Funding Details	The user provides a tariff, contract and other document reference number for each segment of the circuit.
23	Contract Friendly Name	Funding Details	Optional. To create a unique identifier for this request, the user simply enters a nickname (e.g., Smith Telecommunications FY 2016).
24	Expense/Service Type	Funding Details	The user selects the expense/service type (from a list) for the line item. (e.g. T-1)
25	Multiple Service Providers	Funding Details	The user indicates if its service is provided using multiple connections and is provided by multiple service providers; If “YES,” then the user provides further information on the individual service providers. The information collected for multiple service providers is the same fields/inputs as that which is collected for one service provider for the entire circuit.
26	Circuit Bandwidth	Funding Details	The user enters the bandwidth for expense/service type.
27	Circuit ID	Funding Details	The user enters a service provider-specific identifier assigned to the connection between two locations for the line item. The Circuit ID is located on the service provider invoice.
28	Circuit Diagram	Funding Details	If applicable. If HCP is part of a large organization (consortium, network, etc.) or uses multiple service providers for the service, then it must include a diagram to show how the sites interconnect and which carrier(s) provide each circuit segment.
29	Total Billed Circuit Miles	Funding Details	Auto-calculated by the system. The sum of all miles billed by all services providers for that circuit.
30	Maximum Allowable Distance	Funding Details	Auto-populated by the system: Based on information provided on the FCC Form 465.
31	Circuit Start Location	Funding Details	The physical location and/or Site Number where the circuit originates for the line item.
32	Circuit End Location	Funding Details	The physical location and/or Site Number where the circuit terminates for the line item.
33	Satellite Delivery	Funding Details	The user selects if the service is delivered by satellite. If “Yes,” then the user must provide the urban and rural rates for the functionally similar wireline service.
34	Inclusion of Ineligible Services/Sites	Funding Details	The user indicates if the line item includes services or sites that are ineligible.
35	Percentage of Expense Eligible	Funding Details	The user enters the percentage of the expense that is eligible for support. If the entire expense is eligible, enter “100%”. For example, a vendor may provide a bundle that includes both eligible and ineligible services. If percentage is less than 100%, then the user must briefly explain how the percentage was derived.
36	Percentage of Usage Eligible	Funding Details	The user enters the percentage of the usage that is eligible for support. If all of the usage is eligible, enter “100%”. An applicant should use this column to indicate the eligible portion of a connection that is used by both eligible and ineligible sites.
37	Billing Account Number (BAN)	Funding Details	The line item BAN listed on the service provider’s bill.
38	Initial Contract Length	Contract Selection Details	The length of the initial contract excluding voluntary options. Does not include any optional extensions.
39	Contract Expiration Date	Contract Selection Details	The date the signed contract will expire. Does not include any optional extensions.
40	Number of Contract Extensions, Options and/or Upgrades	Contract Selection Details	If the contract includes voluntary options to extend the term of the contract and/or upgrade services, then the user enters the number of such voluntary options.
41	Combined Optional Extension(s) Length	Contract Selection 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.
42	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).
43	Expected Service Start Date	Contract Selection Details	The date service is expected to start.
44	Actual Rural Rate per Month	Funding Details	The amount the site pays per month or the expected amount to be paid per month for the service.
45	Service Level Agreement (SLA)	Contract Selection Details	The indication that the applicant’s contract with the service provider includes an SLA.
46	Quantity of Items	Funding Details	The number of items the applicant is seeking under this line item.
47	Processing: Type Funding Request	Funding Details	The user indicates the type of funding the applicant is requesting (e.g. multi-year, month-to-month, etc.)
48	Billed Circuit Miles	Funding Details: Mileage-based Requests and Comprehensive Rate Request	The billed miles for each connection.
49	Monthly Mileage Charges	Funding Details: Mileage-based Requests and Comprehensive Rate Request	The monthly mileage charges for the service.
50	Cost per Mile per Month	Funding Details: Mileage-based Requests and Comprehensive Rate Request	The cost per mile per month for each connection.
51	Installation Urban Rate Charge	Funding Details: Comprehensive Rate Request	The one-time urban rate charge for the service listed in any city in the site’s state with a population of 50,000 or more.
52	Installation Rural Rate Charge	Funding Details: Comprehensive Rate Request	The amount the service provider will charge the billed entity to install the service listed.
53	Monthly Urban Rate Charge	Funding Details: Comprehensive Rate Request	The monthly urban rate for the service listed.
54	Taxes & Fees Per Expense Period	Funding Details	The taxes and fees for the line item.
55	Supporting Documentation	Documentation	Optional. This option allows the user to upload and submit documents to support their request.
56	I certify that the above named entity has considered all bids received and selected the most cost-effective method of providing the requested service or services. The "most cost-effective service" is defined in the 47 C.F.R. § 54.603(b)(4) as the service available at the lowest cost after consideration of the features, quality of transmission, reliability, and other factors that the health care provider deems necessary for the service to adequately transmit the health care services required by the health care provider.	Certifications	This certification is required in order to submit the funding request.
57	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 universal service benefits provided under 47 U.S.C. § 254. I understand that any letter from RHC that erroneously states that funds will be made available for the benefit of the applicant may be subject to rescission.	Certifications	See #56, Purpose/Instructions.
58	I hereby certify that the billed entity will retain complete billing records for the service for five years.	Certifications	See #56, Purpose/Instructions.
59	I certify that I am authorized to submit this request on behalf of the above-named Billed Entity and HCP, and that I have examined this form and attachments and that to the best of my knowledge, information, and belief, all statements of fact contained herein are true.	Certifications	See #56 Purpose/Instructions.
60	Signature	Signature	The FCC Form 465 must be certified electronically.
61	Date Submitted	System Populated	Auto populated by system.
62	Date Signed	System Populated	Auto populated by system.
63	Authorized Person Name	Signature	This is the name of the Authorized Person signing the FCC Form 465.
64	Authorized Person’s Employer	Signature	This is the name of the employer of the Authorized Person signing the FCC Form 465.
65	Authorized Person’s Employer FCC RN	Signature	This is the FCC RN of the Authorized Person signing the FCC Form 465.
66	Authorized Person’s Title/Position	Signature	This is the title of the Authorized Person signing the FCC Form 465.
67	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.
68	Authorized Person Telephone Number	Signature	This is the telephone number of the Authorized Person signing the FCC Form 465.
69	Authorized Person Email Address	Signature	This is the email address of the Authorized Person signing the FCC Form 465.

5