Federal Government

Rural Health Care Universal Service Community Mental Health Center Checklist

OMB Approved 3060-0804

Estimated time per response:30 minutes

To verify the eligibility of this Community Mental Health Center to participate in the Rural Health Care Support Mechanism, complete the following information and provide a copy of the health care provider’s (HCP) operating license and the operating license/certification number. This form and the HCP’s operating license (and the operating license/certification number) must be submitted with the FCC Form 460 or 465.

To the extent the Community Mental Health Center includes a long-term care facility, such as a residential substance abuse treatment center, that portion would not be eligible for support.

Complete the information below and check the services provided at the physical location of the HCP:

HCP NUMBER (if known):

HCP NAME:

HCP PHYSICAL ADDRESS:

State License/Certification (if available): For the above physical location, provide a copy of the state license/certification and provide the license/certification number:

Services Provided at the Physical Location (check all that apply):

The facility offers outpatient mental health treatment.

The facility offers 24-hour emergency care for mental health patients.

The facility provides day hospital treatment for mental health patients.

The facility provides other partial hospitalization services for mental health patients.

The facility provides psychosocial rehabilitation services.

The facility provides pre-admission screening for patients being considered for admission to state mental health facilities.

The facility provides residential treatment.

Signature:		Date:
Name:		Title:
Email:		Phone:

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 0.5 hours.  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.