State, Local or Tribal Governments

Promoting Telehealth for Low-Income Consumers; COVID-19 Telehealth Program

Telecom Program Invoice Form

State, Local or Tribal Governments

OMB: 3060-1271

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OMB 3060-0804

2/19/2021


Rural Health Care

Telecommunications Program

Invoice Form

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.

This form is effective for funding year 2021.

Item #

Field Description

Purpose/Instructions

1

Service Provider Name

Auto-generated by the system: This is the name of the service provider submitted on the FCC Form 466.

2

498 ID for the Service Provider

Auto-generated by the system: The selected service provider’s 498 ID (formerly the Service Provider Identification Number (SPIN) ID). The 498 ID is pulled from the FCC Form 466 for an FRN.

3

Invoice Number

This number is listed on the service provider’s bill.

4

Invoice Date

The date that the invoice is submitted to the Administrator.

6

Health Care Provider (HCP) Number

Auto-generated by the system: This is the unique identifier included on the Request for Funding (FCC Form 466).

7

Funding Request Number (FRN)

Auto-generated by the system: This is a unique identifier auto-generated by the system on the FCC Form 466 and provided in the funding commitment letter to the applicant.

8

Funding Year: Funding Start Date

Auto-generated by the system: This displays the date funding began for this FRN. Taken from information provided on the Request for Funding (FCC Form 466). Funding years start on July 1 of each year and end on June 30 of the following year.

9

Funding Year: Funding End Date

Auto-generated by the system: This displays the date funding will end/ended for this FRN. Taken from information provided on the FCC Form 466.

10

HCP Entered Billing Account Number (BAN)

The BAN is listed on the service provider’s bill.

11

Service Start Date

User enters the service date for the provided service.

12

Billing Period Start Date

The first date of the billing period for the invoice.

13

Billing Period End Date

The last date of the billing period for the invoice.

14

Support Amount to be Paid by USAC

The system will calculate and display the total amount of the line item expense that may be paid by USAC for the line item.

16

Supporting Documentation

Optional. Provides the option for the user to upload and submit documents to support its invoice form.

17

I certify under penalty of perjury that I am authorized to submit this invoice form on behalf of the service provider.

The service provider’s representative must provide this certification to participate in the RHC Program. The Authorized Person is required to provide all required certifications and signatures.

18

I certify under penalty of perjury that the information contained in the invoice is correct and the applicant(s) and the Billed Account Number(s) listed above have been credited with the amounts shown under “Support Amount to be Paid by USAC.”

See Item 17 Purpose/Instructions above.

20

I certify under penalty of perjury that I have complied with all RHC Program requirements, including all applicable Commission rules.

See Item #17 Purpose/Instructions above.

21

I certify under penalty of perjury that I have received and reviewed the Health Care Provider Support Schedule, invoice form and accompanying documentation, and that the rates charged for the provided or delivered telecommunications services, to the best of my knowledge, information and belief, are accurate and comply with the Commission’s rules.

See Item #17 Purpose/Instructions above.

22

I certify under penalty of perjury that the applicant paid the appropriate urban rate for the telecommunications services.

See Item #17 Purpose/Instructions above.

23

I certify under penalty of perjury that I charged for only eligible services provided or delivered to the applicant prior to submitting the invoice for payment and accompanying documentation.

See Item #17 Purpose/Instructions above.

24

I certify under penalty of perjury that I have not offered or provided a gift or any other thing of value to the applicant (or to the applicant’s personnel, including its consultant).

See Item #17 Purpose/Instructions above.

25

I certify under penalty of perjury that any consultants or third parties associated with this funding request or application do not have an ownership interest, sales commission arrangement, or other financial stake in the service provider chosen to provide the requested services, and that they have otherwise complied with RHC Program rules, including the Commission’s rules requiring fair and open competitive bidding.

See Item #17 Purpose/Instructions above.

26

I certify under penalty of perjury, as a condition of receiving support, that I will provide to applicants, on a timely basis, all information and documents regarding supported equipment, facilities, or services that are necessary for the applicant to submit required forms or respond to Commission or Administrator inquiries.

See Item #17 Purpose/Instructions above.

27

I understand that all documentation related to the delivery of supported services or demonstrate compliance with the rules must be retained for a period of at least five years after the last day of the delivery of discounted services pursuant to 47 CFR § 54.631, or as otherwise prescribed by the Commission’s rules.

See Item #17 Purpose/Instructions above.

28

I certify under penalty of perjury that no universal service support has been or will be used to purchase, obtain, maintain, improve, modify, or otherwise support any equipment or services produced or provided by any company designated by the Federal Communications Commission as posing a national security threat to the integrity of communications networks or the communications supply chain since the effective date of the designations.


See Item #17 Purpose/Instructions above.

29

I certify under penalty of perjury that no Federal subsidy made available through a program administered by the Commission that provides funds to be used for the capital expenditures necessary for the provision of advanced communications services has been or will be used to purchase, rent, lease, or otherwise obtain, any covered communications equipment or service, or maintain any covered communications equipment or service previously purchased, rented, leased, or otherwise obtained, as required by 47 C.F.R. § 54.10.

See Item #17 Purpose/Instructions above.

30

Signature

The Authorized Person is required to provide all required certifications and signatures. The invoice form must be certified electronically.

31

Date Certified and Submitted

Auto populated by system.

32

Date Signed

Auto populated by system.

33

Authorized Person Name

This is the name of the Authorized Person certifying the invoice form. This field will be auto-populated if the name of the Authorized Person is already within the system.

34

Authorized Person’s Employer

This is the name of the employer of the Authorized Person certifying the invoice form. This field will be auto-populated if already within the system.

35

Authorized Person’s Title/Position

This is the title of the Authorized Person certifying the invoice form. This field will be auto-populated if already within the system.

36

Authorized Person’s Mailing Address

This is the address (can be physical address or mailing address) of the Authorized Person certifying the invoice form. This field will be auto-populated if already within the system.

37

Authorized Person’s Telephone Number

This is the telephone number of the Authorized Person certifying the invoice form. This field will be auto-populated if already within the system.

38

Authorized Person’s Email Address

This is the email address of the Authorized Person certifying the invoice form. This field will be auto-populated if already within the system.

39

Authorized Person’s Fax Number

This is the fax number of the Authorized Person certifying the invoice form. This field will be auto-populated if already within the system.



***

FCC NOTICE FOR INDIVIDUALS REQUIRED BY THE PAPERWORK REDUCTION ACT

The public reporting for this collection of information is estimated to be up to 8 hours 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 (3060-0804), 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 3060-0804.

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.



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