Form FCC Form 460 FCC Form 460 Description of Eligibility and Registration

Rural Health Care

Healthcare Connect Fund Program

Description of Eligibility and Registration FCC Form 460

(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	Applicant’s FCC Form Nickname	Request Information	To create a unique identifier for this request, the user simply enters a nickname (e.g., 2016 Funding Year Homewood FCC Form 460).
2	FCC Form 460 Application Number	System Generated	Auto-generated by the system: This is a USAC-assigned unique identifier for this request. This number is automatically created when a user creates an FCC Form 460.
3	Site Name	Site Information	This is the name of the organization submitting this request.
4	Legal Entity Name	Site Information	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 Entity or Consortium Name.
5	Legal Entity FCC Registration Number	Site Information	This is the unique FCC identifier for the Legal Entity that owns and/or operates the site.
6	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.
7	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. This number is automatically created when a user creates an FCC Form 460.
8	National Provider Identifier (NPI)	Site Information	This is the ten-digit health care facility NPI used on Medicare and Medicaid claims.
9	Organization Taxonomy Code	Site Information	This is the ten-digit Healthcare Provider Taxonomy Code that corresponds to the NPI.
10	Site Taxonomy Code	Site Information	Optional. Should the Organization Taxonomy Code not adequately describe the site, the user may add additional Taxonomy Codes.
11	Site Address	Site Information	This is the site’s physical address, county, city, state, zip code and geolocation. Geolocation only applies to a site that does not have a street address.
12	Site Website	Site Information	Optional. The website address of the site.
13	Type of Registration	Site Information	This is the selection of the applicant as a health care provider (HCP) site, Consortium, Off-site data center, Off-site administrative office or Ineligible site.
14	Type of Registration: If Data Center	Site Information	A list of all sites (eligible and ineligible) that will use the services of the data center.
15	Type of Registration: If Administrative Center	Site Information	A list of all sites (eligible and ineligible) that will use the services of the administrative center.
16	Eligibility Entity Type that Seeks Support	Site Information	These are the eligible health care provider categories as provided in 47 C.F.R. §54.600(a): Community health center or health center providing health care to migrants; community mental health center; local health department/agency; non-profit hospital; part-time eligible entity located in an ineligible facility; post-secondary educational institution offering health care instruction; teaching hospital or medical school; rural health clinic; dedicated emergency room (ER) of rural, for-profit hospital; skilled nursing facility; consortium of the above.
17	Eligibility Entity Type that Seeks Support: If Rural Health Clinic	Site Information	If the user chooses “Rural Health Clinic,” the user selects whether or not the site is a mobile rural HCP.
18	Eligibility Entity Type that Seeks Support: If Non-Profit Hospital	Site Information	If the user chooses “Non-Profit Hospital,” then the user indicates if the hospital is a Critical Access Hospital.
19	Eligibility Entity Type that Seeks Support: If Non-Profit Hospital	Site Information	If the user chooses “Non-Profit Hospital,” then the user will be asked to define how many licensed patient beds are on site.
20	Eligibility Entity Type that Seeks Support: If Community Mental Health Center	Site Information	If the user chooses “Community Mental Health Center,” then the user must submit the Community Mental Health Center Checklist and a copy of the HCP’s operating license.
21	Eligibility Entity Type that Seeks 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	Eligibility Entity Type that Seeks Support: Additional Site Information	Site Information	Optional. The user has the ability to provide a brief explanation of why the site qualifies as the eligibility category selected.
23	Consortium Name	Consortium Details	The name of the consortium.
24	Consortium Number	System Generated	The unique identifier assigned by USAC to the consortium listed in Consortium Name.
25	Consortium: Legal Entity Identification	Consortium Details	The user indicates if the consortium is a Legal Entity.
26	Consortium FCC Registration Number	Consortium Details	This is the unique FCC identifier for the consortium.
27	Consortium Leader Name	Consortium Details	This is the organization that will serve as the main point of contact for USAC and the FCC, and who will act on behalf of the consortium members.
28	Consortium Leader Type	Consortium Details	The user identifies the consortium as either: an eligible Healthcare Provider member of the consortium, State organization, Public sector (government) entity, Non-Profit entity, or Consortium itself if organized as a Legal Entity. A state organization, public sector entity, or non-profit entity may obtain an exemption to allow the organization to perform vendor functions and provide application assistance.
29	Consortium Leader: If Eligible Healthcare Provider Member	Consortium Details	If the user selects “Eligible healthcare provider member of the consortium,” then they provide a site number for their site.
30	Written Agreement Allocating Legal and Financial Responsibility	Consortium Details	The user indicates if the consortium has a written agreement allocating legal and financial responsibility. By default, the consortium leader is the legally and financially responsible entity for the conduct of activities supported by the universal service fund.
31	Written Agreement Allocating Legal and Financial Responsibility: Yes	Consortium Details	User uploads Written Agreement Allocating Legal and Financial Responsibility document.
32	Exemption for State/Non-Profit Entities Serving as Both Vendor and Consortium Leader/Consultant	Consortium Details	For consortia only. An entity seeking to obtain an exemption from not being able to serve as both the vendor and the consortium leader/consultant, must make a showing to USAC that they have set up an organizational and functional separation. This exemption must be obtained before preparing the FCC Form 461 and associated documents.
33	Exemption for State/Non-Profit Entities Serving as Both Vendor and Consortium Leader/Consultant: Yes		User provides written documentation showing that they have set up an organizational and functional separation.
34	Consortium Leader Address	Consortium Details	This is the consortium mailing address, county, city, state, and zip code.
35	Consortium Website	Consortium Details	Optional. The website address of the consortium.
36	Primary Account Holder Contact Name	Contact Information	This is the name of the person who should be contacted with questions about this request. The Consortium Leader or Entity must designate a Primary Contact for purposes of interacting with USAC. This person must be employed by the Legal Entity listed on this FCC Form. The Primary Contact has the ability to view, create, and enter data in the forms, and electronically certify, sign and submit forms, on behalf of the Entity or Consortium.
37	Primary Contact Employer	Contact Information	This will auto-populate to be the information listed within “Legal Entity Name” (Item # 4).
38	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.
39	Primary Contact Telephone Number	Contact Information	This is telephone number of the person who should be contacted with questions about this request.
40	Primary Contact Email Address	Contact Information	This is the email address of the person who should be contacted with questions about this request.
41	Legal Entity Website	Contact Information	Optional. The website address of the Legal Entity that owns and/or operates the Entity or Consortium. Explains more about what the Legal Entity is in relation to a site and consortium. This is the website for the organization listed in Item #4.
42	Additional Contact(s)	Contact Information	Optional. Allows the user to add additional contact person(s) to the request. Additional contacts will have access to forms and have the ability to answer specific questions about the applications associated with a funding request. They also have the ability to sign, certify and submit forms on behalf of the applicant. 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.
43	Supporting Documentation	Documentation	Optional. Provides an option for the user to upload and submit documents to support their request.
44	I certify that I am authorized to submit this request on behalf of the site or consortium.	Certifications	The Authorized Person is required to make all required certifications and signatures.
45	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 #44, Purpose/Instructions above.
46	I understand that all documentation associated with this request 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 #44, Purpose/Instructions above.
47	If applying as an individual Healthcare Provider site, I certify that the Healthcare Provider is either a non-profit, public entity or a dedicated ER of a rural for-profit hospital.	Certifications	See Item #44, Purpose/Instructions above. Only applies to those applying as an individual Healthcare Provider site.
48	If applying as an individual Healthcare Provider site, I certify that the site is located in a FCC designated rural area, or is a grandfathered rural pursuant to 47 C.F.R. § 54.600(b)(2).	Certifications	See Item #44, Purpose/Instructions above. Only applies to those applying as an individual Healthcare Provider site.
49	If applying as a consortium, I certify that the eligible Healthcare Providers participating in the consortium are either non-profit or public entities or dedicated ER(s) of a rural for-profit hospital.	Certifications	See Item #44, Purpose/Instructions above. Only applies to those applying as a consortium.
50	If applying as a consortium, I understand I must obtain letters of agency from each consortium member that grants me the authority to complete, sign, and submit all requests for the funding year(s) for which support is sought.	Certifications	See Item #44, Purpose/Instructions above. Only applies to those applying as a consortium.
51	Signature	Signature	The Authorized Person is required to make all required certifications and signatures. The request must be certified electronically.
52	Date Submitted	System Generated	Auto generated by system: This date is assigned based on the date the user submits the FCC Form 460.
53	Date Signed	System Generated	Auto generated by system: This date is assigned based on the date the user signs the FCC Form 460.
54	Authorized Person	Signature	This is the name of the Authorized Person (either the Primary Contact or an Additional Contact) that is signing the FCC Form.
55	Authorized Person’s Employer	Signature	Auto-generated by the system: Based on either previous information entered in this FCC Form 460 or based on the details of the logged in user. This is the name of the employer of the Authorized Person signing the FCC Form.
56	Authorized Person’s Employer FCC Registration Number	Signature	Auto-generated by the system: Based on either previous information entered in this FCC Form 460 or based on the details of the logged in user. This is the FCC Registration Number of the Authorized Person signing the FCC Form. This number may be the FCC RN of the Legal Entity, Consortium or Site.
57	Authorized Person’s Title/Position	Signature	Auto-generated by the system: Based on either previous information entered in this FCC Form 460 or based on the details of the logged in user. This is the title or position of the Authorized Person signing the FCC Form.
58	Authorized Person’s Mailing Address	Signature	Auto-generated by the system: Based on either previous information entered in this FCC Form 460 or based on the details of the logged in user. This is the address (can be physical address or mailing address) of the Authorized Person signing the FCC Form.
59	Authorized Person Telephone Number	Signature	Auto-generated by the system: Based on either previous information entered in this FCC Form 460 or based on the details of the logged in user. This is the telephone number of the Authorized Person signing the FCC Form.
60	Authorized Person Email Address	Signature	Auto-generated by the system: Based on either previous information entered in this FCC Form 460 or based on the details of the logged in user. This is the email address of the Authorized Person signing the FCC Form.
61	Third Party Authorization (TPA)	Request Information	If applicable, the user must provide a TPA providing written authorization to a third party/consultant to complete and submit the FCC Form on behalf of the Healthcare Provider or consortium.
62	Letter of Agency (LOA)	Consortium Details	For Consortia only. If applicable, the user must provide an LOA providing written authorization to the Primary or Additional Contact(s) of a consortium to act on behalf of each participating Healthcare Provider or health system not owned or operated by the consortium or organization operating the consortium.
63	Letter of Exemption (LOE)	Consortium Details	For Consortia only. If applicable, the user must provide an LOE providing written authorization to the Primary or Additional Contact(s) of a consortium to submit requests for sites owned and operated by the consortium.

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