State, Local or Tribal Governments

[insert date of Letter of Authorization]

Office of the Secretary
Federal Communications Commission
445 12th Street, S.W.
Washington, D.C. 20554
Funding Commitment Date: [insert date]
Funding Commitment Number: [insert number located on funding commitment notification]
Health Care Provider Name: [insert name]
Health Care Provider Number: [insert your HCP no. provided by USAC]
Subject: Letter of Authorization
FCC Staff,
[insert entity name that submitted application and received the funding commitment] applied for
funding under the COVID-19 Telehealth Program and received a funding commitment on our
behalf as the consortium lead. We therefore authorize [insert entity name that submitted
application and received the funding commitment] to accept disbursements of funding under the
COVID-19 Telehealth Program on our behalf. We understand that any funding received by
[insert entity name that submitted application and received the funding commitment] shall be
provided to our health care provider site to reimburse us for the respective costs incurred under
the COVID-19 Telehealth Program. We also understand and certify under penalty of perjury
that this funding shall only be used by eligible health care providers to obtain the
telecommunications services, information services, and connected devices to provide telehealth
services in response to the coronavirus 2019 disease (COVID-19) pandemic.
Should you have any questions or need further information, please contact me at your
convenience.

Sincerely,

[signature]
______________________________________________
[insert printed name of Authorized Person to sign on behalf of the HCP]
[insert title of Authorized Person]

__________
Date

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FCC NOTICE FOR INDIVIDUALS REQUIRED BY THE PAPERWORK REDUCTION ACT
The public reporting for this collection of information is estimated to be up to 1 hour per response,
including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the required data, and completing and reviewing the collection of information. If you
have any comments on this burden estimate, or how we can improve the collection and reduce the
burden it causes you, please write to the Federal Communications Commission, AMD-PERM,
Paperwork Reduction Act Project (3060-1271), Washington, DC 20554. We will also accept your
comments regarding the Paperwork Reduction Act aspects of this collection via the Internet if you
send them to [email protected]. PLEASE DO NOT SEND YOUR RESPONSE TO THIS FORM 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 if we fail to provide you with this notice. This collection has
been assigned an OMB control number of 3060-1271.
THE FOREGOING NOTICE IS REQUIRED BY THE PAPERWORK REDUCTION ACT OF 1995,
PUBLIC LAW 104-13, OCTOBER 1, 1995, 44 U.S.C. SECTION 3507.