FCC Form 465 RHC, Telecommunications Program, Description of Eligibil

OMB 3060-0804

X/X/2020

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.

This form is effective for funding year 2020.

Item #		Field Description		Purpose/Instructions
1		FCC Form 465 Application Number		Auto generated by system. This is a unique Universal Service Administrative Company (USAC)-assigned unique identifier for this request.
2		Applicant’s FCC Form Nickname		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		This is the name of the site.
4		Site Number		Auto generated by system. This is the unique USAC assigned identifier for the site listed in Site Name.
5		Site Address		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		Optional. The website address of the site.
7		Site FCC Registration Number (FCC RN)		This is the site’s unique FCC RN identifier.
8		Employer Identification Number (EIN)		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)		The ten-digit health care facility NPI that is used on Medicare and Medicaid claims.
10		Organization Taxonomy Code		This is the ten-digit Health Care Provider Taxonomy Code that corresponds to the NPI.
11		Site Taxonomy Code		Optional. Should the Organization Taxonomy Code not adequately describe the site, the user may add additional Taxonomy Codes.
12		Legal Entity Name		If applicable. This is the name of the Legal Entity that owns and/or operates the site. In some cases, the Legal Entity Name may be different from the Site Name.
13		Legal Entity FCC RN		If applicable. This is the unique FCC identifier for the Legal Entity that owns and/or operates the site.
14		Legal Entity Contact		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		Consortium Name		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		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		These are the eligible health care provider categories as provided in 47 CFR § 54.600(b): community health center or health center providing health care to migrants; community mental health center; local health department or agency; non-profit hospital; post-secondary educational institution offering health care instruction, including a teaching hospital or medical school; rural health clinic; skilled nursing facility; and consortium of the above entities. In addition, a dedicated emergency room (ER) of a rural, for-profit hospital and part-time eligible entity located in an ineligible facility are eligible for support under the RHC Program. Only an entity that is either a public or non-profit health care provider is eligible for support. 47 CFR § 54.601(a)(1). Each separate site or location of a health care provider shall be considered an individual health care provider for purposes of calculating support. 47 CFR § 54.601 (a)(2)
18		Eligibility Entity Type Requests Support: If Consortium, Dedicated Emergency Department or Part-Time Eligible Entity		The user further describes the site if it qualifies as one of these types of sites.
19		Eligibility Entity Type that Seek Support: If Community Mental Health Center		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 operating license
20		Eligibility Entity Type Requests Support: Additional 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		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	Services Requested: Category		The user details which category(s) of services/activities the site is requesting.
23		Services Requested: Service/Activity 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		Services Requested: Desired Contract Length		The user provides details on the length and type of contract requested.
25		Services Requested: Bid Posting Period		Optional. The user may add days on to the posting period beyond the required minimum 28-day posting period.
26		Bidding Evaluation		The user develops 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. “Cost-effective” 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.
27		Primary Contact Name		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		This will auto-populate to be the information listed within “Legal Entity Name.”
29		Primary Contact Title		This is the title of the person who should be contacted with questions about this request.
30		Primary Contact Mailing Address		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		This is the telephone number of the person who should be contacted with questions about this request.
32		Primary Contact Email Address		This is the email address of the person who should be contacted with questions about this request.
33		Primary Contact Fax Number		This is the fax number of the person who should be contacted with questions about this request.
34		Additional Contact(s)		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		Declaration of Assistance		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.
36		Letter of Authorization		If applicable, the user must provide a letter of authorization which provides written authorization to a third party/consultant to complete and submit FCC Forms on behalf of the health care provider for the Telecommunications Program.
37		Supporting Documentation		Optional. This provides an option for the user to upload and submit any other documents to support their request.
38		I certify under penalty of perjury that I am authorized to submit this request on behalf of the applicant or consortium.		The Authorized Person is required to provide all required certifications and signatures. An officer or director of the applicant must sign all certifications. The applicant must provide this certification in order to receive universal service support.
39		I certify under penalty of perjury that I have examined this request and all attachments, and to the best of my knowledge, information, and belief, all statements contained herein and in any attachments are true.		See Item #38 Purpose/Instructions above.
40		I certify under penalty of perjury that the applicant has complied with all applicable state, Tribal, or local procurement rules.		See Item #38 Purpose/Instructions above.
41		I certify under penalty of perjury that all requested RHC Program support will be used solely for purposes reasonably related to the provision of health care service or instruction that the applicant is legally authorized to provide under the law of the state in which the services are provided.		See Item #38 Purpose/Instructions above.
42		I certify under penalty of perjury that the supported services will not be sold, resold, or transferred in consideration for money or any other thing of value.		See Item #38 Purpose/Instructions above.
43		I certify under penalty of perjury that the applicant seeking supported services is a public or non-profit entity that falls within one of the seven categories set for in the definition of health care provider listed in 47 CFR § 54.600 of the Commission’s rules.		See Item #38 Purpose/Instructions above.
44		I certify under penalty of perjury that the applicant seeking support services is physically located in a rural area as defined in section 47 CFR § 54.600 of the Commission’s rules.		See Item #38 Purpose/Instructions above.
45		I certify under penalty of perjury that the applicant satisfies all of the requirements under section 254 of the Communications Act and applicable Commission rules.		See Item #38 Purpose/Instructions above.
46		I certify under penalty of perjury that the applicant has reviewed and will comply with all applicable RHC Program requirements.		See Item #38 Purpose/Instructions above.
47		I understand that all documentation associated with this request must be retained for a period of at least five years pursuant to 47 CFR § 54.631, or as otherwise prescribed by the Commission’s rules.		See Item #38 Purpose/Instructions above.
48		Signature		The FCC Form 465 must be certified electronically.
49		Date Submitted		Auto generated by system.
50		Date Signed		Auto generated by system.
51		Authorized Person		The Authorized Person is required to provide all required signatures and certifications. The FCC Form 465 must be certified electronically. This field will be auto-populated if the name of the Authorized Person is already within the system.
52		Authorized Person’s Employer		This is the name of the employer of the Authorized Person certifying the FCC Form 465. This field will be auto-populated if already within the system.
53		Authorized Person’s Employer FCC RN		This is the FCC RN of the Authorized Person certifying the FCC Form 465. This field will be auto-populated if already within the system.
54		Authorized Person’s Title/Position		This is the title of the Authorized Person certifying the FCC Form 465. This field will be auto-populated if already within the system.
55		Authorized Person’s Mailing Address		This is the address (can be physical address or mailing address) of the Authorized Person certifying the FCC Form 465. This field will be auto-populated if already within the system.
56		Authorized Person Telephone Number		This is the telephone number of the Authorized Person certifying the FCC Form 465. This field will be auto-populated if already within the system.
57		Authorized Person Email Address		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.

FCC NOTICE FOR INDIVIDUALS REQUIRED BY THE PRIVACY ACT AND THE PAPERWORK REDUCTION ACT

Part 54 of the Federal Communications Commission’s (FCC) rules authorize the FCC to collect the information in this form. Responses to the questions herein are required to obtain the benefits sought by this form. Failure to provide all requested information will delay the processing of the form or result in the form being returned without action. Information requested by this form will be available for public inspection. The information provided will be used to determine whether approving the request is in the public interest.

We have estimated that your response to this collection of information will take 1 hour.  Our estimate includes the time to read the instructions, look through existing records, gather and maintain the required data, and actually complete and review the form or response.  If you have any comments on this estimate, or on how we can improve the collection and reduce the burden it causes you, please write the Federal Communications Commission, Office of Managing Director, AMD‑PERM, Paperwork Reduction Act Project (3060‑0804), Washington, DC 20554.  We will also accept your comments via the Internet if you send them to [email protected].  Please DO NOT SEND COMPLETED FORMS TO THIS ADDRESS.  

Remember – you are not required to respond to a collection of information sponsored by the Federal government, and the government may not conduct or sponsor this collection, unless it displays a currently valid OMB control number or we fail to provide you with this notice.  This collection has been assigned an OMB control number of 3060‑0804.

THIS NOTICE IS REQUIRED BY THE PAPERWORK REDUCTION ACT OF 1995, P.L. 104-13, OCTOBER 1, 1995, 44 U.S.C. SECTION 3507.

13