COVID-19 Telehealth Program Application Form

COVID-19 Telehealth Application
Applicants should submit their completed application form and all
supporting documentation to [email protected]

OMB Control No. 3060-1271
2-19-2021

Applicant Information [all fields mandatory unless otherwise marked]

Applicant Name

Applicant FCC
Registration Number(FRN)

Federal Employer Identification Number
(EIN or Tax ID Number)

Applicant National
Provider Identifier
(Optional)

Data Universal Numbering System (DUNS) Number

DATA Act Business Types (Choose Three)
A - State Government
B - County Government
C - City or Township Government
D - Special District Government
E - Regional Organization
F - U.S. Territory or Possession
G - Independent School District
H - Public/State Controlled Institution of Higher Education
I - Indian/Native American Tribal Government (Federally-Recognized)
J - Indian/Native American Tribal Government (Other than Federally-Recognized)
K - Indian/Native American Tribal Designated Organization
L - Public/Indian Housing Authority
M - Nonprofit with 501C3 IRS Status (Other than an Institution of Higher Education)
N - Nonprofit without 501C3 IRS Status (Other than an Institution of Higher Education)
O - Private Institution of Higher Education
P - Individual
Q - For-Profit Organization (Other than Small Business)
R - Small Business
S - Hispanic-serving Institution
T - Historically Black College or University (HBCU)
U - Tribally Controlled College or University (TCCU)
V - Alaska Native and Native Hawaiian Serving Institutions
W - Non-domestic (non-U.S.) Entity
X - Other
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Service Area

Contact Information [all fields mandatory]
First Name

Last Name

Position Title, Company Name

Mailing Address
Street

City

Phone Number

State

Zip

E-mail Address

2

Health Care Provider(s) (HCP) Information [lead fields mandatory unless
otherwise noted]

Lead HCP

Facility Name

Is the Facility a Hospital?
Yes
No

Street

City

State

Zip

County in which address is located

FCC Registration Number
(FRN)

HCP Number (Optional)

Eligibility Type

NPI (Optional)

Total Patient Population

Estimated Number of Patients to be
Served by Funding Request

Additional Information on Patient Estimate (Optional)

3

Health Care Provider(s) (HCP) Information [HCP Two- Optional fields ]

HCP

Facility Name

Is the Facility a Hospital?
Yes
No

Street

City

State

Zip

County in which address is located

FCC Registration Number
(FRN)

HCP Number (Optional)

Eligibility Type

NPI (Optional)

Total Patient Population

Estimated Number of Patients to be
Served by Funding Request

Additional Information on Patient Estimate (Optional)

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Health Care Provider(s) (HCP) Information [HCP Three- Optional fields ]

HCP

Facility Name

Is the Facility a Hospital?
Yes
No

Street

City

State

Zip

County in which address is located

FCC Registration Number
(FRN)

HCP Number (Optional)

Eligibility Type

NPI (Optional)

Total Patient Population

Estimated Number of Patients to be
Served by Funding Request

Additional Information on Patient Estimate (Optional)

5

Health Care Provider(s) (HCP) Information [HCP Four- Optional fields ]

HCP

Facility Name

Is the Facility a Hospital?
Yes
No

Street

City

State

Zip

County in which address is located

FCC Registration Number
(FRN)

HCP Number (Optional)

Eligibility Type

NPI (Optional)

Total Patient Population

Estimated Number of Patients to be
Served by Funding Request

Additional Information on Patient Estimate (Optional)

6

Health Care Provider(s) (HCP) Information [HCP Five- Optional fields ]

HCP

Facility Name

Is the Facility a Hospital?
Yes
No

Street

City

State

Zip

County in which address is located

FCC Registration Number
(FRN)

HCP Number (Optional)

Eligibility Type

NPI (Optional)

Total Patient Population

Estimated Number of Patients to be
Served by Funding Request

Additional Information on Patient Estimate (Optional)

7

Health Care Provider(s) (HCP) Information [HCP Six- Optional fields ]

HCP

Facility Name

Is the Facility a Hospital?
Yes
No

Street

City

State

Zip

County in which address is located

FCC Registration Number
(FRN)

HCP Number (Optional)

Eligibility Type

NPI (Optional)

Total Patient Population

Estimated Number of Patients to be
Served by Funding Request

Additional Information on Patient Estimate (Optional)

8

Health Care Provider(s) (HCP) Information [HCP Seven- Optional fields ]

HCP

Facility Name

Is the Facility a Hospital?
Yes
No

Street

City

State

Zip

County in which address is located

FCC Registration Number
(FRN)

HCP Number (Optional)

Eligibility Type

NPI (Optional)

Total Patient Population

Estimated Number of Patients to be
Served by Funding Request

Additional Information on Patient Estimate (Optional)

9

Health Care Provider(s) (HCP) Information [HCP Eight- Optional fields ]

HCP

Facility Name

Is the Facility a Hospital?
Yes
No

Street

City

State

Zip

County in which address is located

FCC Registration Number
(FRN)

HCP Number (Optional)

Eligibility Type

NPI (Optional)

Total Patient Population

Estimated Number of Patients to be
Served by Funding Request

Additional Information on Patient Estimate (Optional)

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Medical Services To Be Provided with COVID-19 Telehealth Funding (check all that apply)
Patient-Based Internet-Connected Remote Monitoring
Other Monitoring
Video Consults
Voice Consults
Imaging Diagnostics
Other Diagnostics
Remote Treatment
Other services
Additional Information on Medical Services to be Provided:

Conditions To Be Treated with COVID-19 Telehealth Funding (answer all that
apply)
Would you treat COVID-19 patients directly?
Yes
No
Would you treat patients without COVID-19 symptoms or conditions?
Yes
No

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If you answered "Yes" to the above question, please check at least one box below
Other infectious diseases
Emergency / Urgent Care
Routine, Non-Urgent Care
Mental Health Services (non-emergency)
Other conditions
Additional Information on Specific Conditions to be Treated:[Required if other conditions is
selected]

If yes, please explain how using COVID-19 Telehealth Program funding to treat patients without
COVID-19 symptoms or conditions would free up resources that will be used to treat COVID-19.
(Required if yes)

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Additional Information Concerning Requested Services and Devices
What are your goals and objectives for use of the COVID-19 Telehealth Program Funding?

What is your timeline for deployment of the proposed service(s) or devices funded by the
COVID-19 Telehealth Program?

13

What factors/metrics will you use to help measure the impact of the services and devices funded
by the COVID-19 Telehealth Program?

How has COVID-19 affected health care in your geographic area (e.g, county)?

14

Please provide additional information about the geographic area and population you serve.
Does it have large underserved or low-income patient population? Have there been recent
health care provider closures or other health care deficiencies? If so, please describe such
factors (Optional)

Do you plan to target the funding to high-risk and vulnerable patients?
Yes
No
If so, please describe how.

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Please provide any additional information to support your application and request for funding
(Optional)

Requested Funding Items

Total Amount of Funding Requested

Are you requesting funding for devices?
Yes
No
How are the devices integral to patient care?

16

Are the devices for patient use?
Yes
No
Are the devices for the health care provider’s use?
Yes
No
Category (Optional)

Description of Service(s) and/or Device(s)(Optional)

Quantity (for Devices)(Optional)

Total One-Time Expense(Optional)

Date [Purchased or] To Be Purchased(Optional)

Total Monthly Expense(Optional)

Number of Months for Recurring Monthly Expenses(Optional)

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Supporting Cost and Estimated Patient Documentation

An applicant should provide supporting documentation for the costs indicated in its application. Such supporting
documentation should summarize the expected costs of the eligible services and devices requested and may include
documentation such as an invoice or quote from a vendor or service provider (or similar information). Such
information should be specific enough to identify line-items to facilitate swift review of the application, and we
encourage applicants to include information such as a description of the service or device, its eligibility category, the
quantity ordered, the upfront and monthly expenses, and the service dates for recurring services. Additionally,
applicants may provide supporting document for the estimated number of patients to be served by the funding
request.

Request for confidential treatment of supporting documentation?
Yes

No

Applicant requests Confidential treatment for supporting documents and information. By designating supporting
documents and information as “Confidential,” the applicant is deemed to have submitted a request that the material
be withheld from public inspection pursuant to 47 CFR § 0.459. Applicants designating supporting documents as
“Confidential” should not submit those documents in the Commission’s Electronic Comment Filing System (ECFS).
Email Confidential materials to [email protected]

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Certifications:
[Applicant must check all boxes and sign]
I certify under penalty of perjury that I am authorized to submit this application on behalf of the health
care provider(s) listed in the application.
I certify under penalty of perjury that to the best of my knowledge, information, and belief, all information
contained in this application, and in any attachments, is true and correct.
I understand that, if selected, the health care provider(s) in the application must comply with all
applicable program requirements and procedures, and all applicable federal and state laws, including
the False Claims Act, the Anti-Kickback Statute, and the Civil Monetary Penalties Law, as waived or
modified in connection with the COVID-19 pandemic, and the Coronavirus Aid, Relief, and Economic
Security (CARES) Act.
I understand that, if selected, the health care providers in the application must comply with the Health
Insurance Portability and Accountability Act (HIPAA) and other applicable privacy and reimbursement
laws and regulations, and applicable medical licensing laws, as waived or modified in connection with
the COVID-19 pandemic.
I understand that all documentation associated with this application must be retained for a period of at
least three years after the last date of delivery of the supported-services provided through the
COVID-19 Telehealth Program to demonstrate compliance with COVID-19 Telehealth Program rules
and requirements, subject to audit.
I certify under penalty of perjury that the health care provider(s) listed in the application, to the best of
my knowledge, is not already receiving or expecting to receive other funding (from any source, private,
state, or federal) for the exact same services or devices eligible for support under the COVID-19
Telehealth Program.
I understand that all requested goods and services funded under the COVID-19 Telehealth Program
must be used for their intended purposes.

Contact Name

Date

If you have an issue with this form and/or need assistance please contact: [email protected].

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FCC NOTICE FOR INDIVIDUALS REQUIRED BY THE PRIVACY ACT AND THE PAPERWORK
REDUCTION ACT
Part 3 of the Commission’s Rules authorize the Commission to request the information on this form. The purpose of
the information is to obtain information from applicants that will be used by the Commission to evaluate the
applications and select applications to receiving funding under the COVID-19 Telehealth Program. In selecting
participants for the COVID-19 Telehealth Program, this information is necessary to select applications that target
areas hardest hit by COVID-19 where the support will have the most impact on addressing immediate health care
needs, determine funding awards and subsequently issue disbursements. Failure to provide the requested
information, may result in an application not being selected for funding under the COVID-19 Telehealth Program.
Information requested by this form may be made available for public inspection after the Commission staff completes
its review. If a request for public inspection under the Commission’s rules is made for an applicant’s information, the
applicant will be notified and then must justify the continued confidential treatment of the information if it objects to
the disclosure.
We have estimated that your response to this collection of information will take an average of 15 hours. Our
estimate includes the time to read the instructions, look through existing records, gather and maintain 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, Washington, DC 20554, Paperwork Reduction Act Project
(3060-1271). We will also accept your PRA comments via the Internet if you send an e-mail to [email protected].
Please DO NOT SEND COMPLETED APPLICATION FORMS TO THIS ADDRESS. 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 and/or we fail to provide you with this
notice. This collection has been assigned an OMB control number of 3060-1271.
THIS NOTICE IS REQUIRED BY THE PRIVACY ACT OF 1974, PUBLIC LAW 93-579, DECEMBER 31, 1974, 5
U.S.C. 552a(e)(3) AND THE PAPERWORK REDUCTION ACT OF 1995, PUBLIC LAW 104-13, OCTOBER 1, 1995,
44 U.S.C. SECTION 3507.

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