Download:
pdf |
pdfNOT YET APPROVED BY OMB
Estimated time per response: 1 hr
OMB 3060-0804
X/XX/2023
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
Purpose/Instructions
1
Applicant’s FCC Form Nickname
2
FCC Form 460 Application Number
3
4
Site Name
Legal Entity Name
5
Legal Entity FCC Registration Number
6
Employer Identification Number (EIN)
7
Site Number
8
9
10
National Provider Identifier (NPI)
Organization Taxonomy Code
Site Taxonomy Code
11
Site Address
12
Site Website
To create a unique identifier for this request, the user simply enters a nickname (e.g.,
2016 Funding Year Homewood FCC Form 460).
Auto-generated by the system: This is a unique USAC-assigned identifier for this
request that is automatically created when a user creates an FCC Form 460.
This is the name of the organization submitting this request.
This is the name of the Legal Entity that owns and/or operates the site. In some cases,
the Legal Entity Name may be different from the Entity or Consortium Name.
This is the unique FCC identifier for the Legal Entity that owns and/or operates the
site.
The EIN, also known as a Federal Tax Identification Number, is used to identify a
business or non-profit entity.
Auto-generated by the system: This is the unique identifier assigned by the Universal
Service Administrative Company (USAC) to the organization identified in the Site
Name. This number is automatically created when a user creates an FCC Form 460.
This is the ten-digit health care facility NPI used on Medicare and Medicaid claims.
This is the ten-digit Health Care Provider Taxonomy Code that corresponds to the NPI.
Optional. Should the Organization Taxonomy Code not adequately describe the site,
the user may add additional Taxonomy Codes.
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.
Optional. The website address of the site.
1
OMB 3060-0804
X/XX/2023
Item #
Field Description
Purpose/Instructions
13
Type of Registration
14
15
Type of Registration: If Data Center
Type of Registration: If Administrative Center
16
Eligibility Entity Type that Seeks Support
17
Eligibility Entity Type that Seeks Support: If
Rural Health Clinic
Eligibility Entity Type that Seeks Support: If
Non-Profit Hospital
Eligibility Entity Type that Seeks Support: If
Non-Profit Hospital
Eligibility Entity Type that Seeks Support: If
Community Mental Health Center
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.
A list of all sites (eligible and ineligible) that will use the services of the data center.
A list of all sites (eligible and ineligible) that will use the services of the administrative
center.
These are the eligible health care provider categories as provided in 47 CFR §
54.600(b): community health center or health center providing health care to
migrants; community mental health center; local health department or agency; nonprofit hospital; post-secondary educational institution offering health care instruction,
including a teaching hospital or medical school; rural health clinic; skilled nursing
facility; and consortium of the above entities. In addition, a dedicated emergency
room (ER) of a rural, for-profit hospital and part-time eligible entity located in an
ineligible facility are eligible for support under the RHC Program. Only an entity that is
either a public or non-profit health care provider is eligible for support. 47 CFR §
54.601(a)(1). Each separate site or location of a health care provider shall be
considered an individual health care provider for purposes of calculating support. 47
CFR § 54.601 (a)(2).
If the user chooses “Rural Health Clinic,” the user selects whether or not the site is a
mobile rural HCP.
If the user chooses “Non-Profit Hospital,” then the user indicates if the hospital is a
Critical Access Hospital.
If the user chooses “Non-Profit Hospital,” then the user will be asked to provide how
many licensed patient beds are on site.
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.
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 Tribal entity.
Optional. The user may provide a brief explanation of why the site qualifies as the
eligibility category selected.
The name of the consortium.
The unique identifier assigned by USAC to the consortium listed in Consortium Name.
18
19
20
21
22
23
24
Eligibility Entity Type that Seeks Support:
Additional Site Information
Eligibility Entity Type that Seeks Support:
Additional Site Information
Consortium Name
Consortium Number
2
OMB 3060-0804
X/XX/2023
Item #
Field Description
Purpose/Instructions
25
26
27
Consortium: Legal Entity Identification
Consortium FCC Registration Number
Consortium Leader Name
28
Consortium Leader Type
29
Consortium Leader: If Eligible Health Care
Provider Member
Written Agreement Allocating Legal and
Financial Responsibility
The user indicates if the consortium is a Legal Entity.
This is the unique FCC identifier for the consortium.
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.
The user identifies the consortium as either: an eligible Health Care 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 service provider functions and provide application assistance.
If the user selects “Eligible health care provider member of the consortium,” then
they must provide a site number for their site.
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.
User uploads “Written Agreement Allocating Legal and Financial Responsibility”
document.
For consortia only. An entity seeking to obtain an exemption to be able to serve as
both the service provider and the consortium leader/consultant, must make a
showing to USAC that they have set up an organizational and functional separation
between the consortium leader/consultant and service provider roles and
responsibilities. This exemption must be obtained before preparing the FCC Form 461
and associated documents.
User provides written documentation showing that they have established and
implemented an organizational and functional separation between the consortium
leader and service provider roles and responsibilities.
30
31
32
33
34
35
Written Agreement Allocating Legal and
Financial Responsibility: Yes
Exemption for State Organization, Public
Sector Entity, or Non-Profit Entity Serving as
Both Service Provider and Consortium
Leader/Consultant
Exemption for State Organization, Public
Sector Entity, or Non-Profit Entity Serving as
Both Service Provider and Consortium
Leader/Consultant: Yes
Consortium Leader Address
Consortium Website
This is the consortium leader mailing address, county, city, state, and zip code.
Optional. The website address of the consortium.
3
OMB 3060-0804
X/XX/2023
Item #
Field Description
Purpose/Instructions
36
Primary Account Holder Contact Name
37
Primary Contact Employer
38
Primary Contact Mailing Address
39
Primary Contact Telephone Number
40
Primary Contact Email Address
41
Legal Entity Website
42
Additional Contact(s)
43
Supporting Documentation
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 the Commission and USAC. This person must be
employed by the Legal Entity listed on this FCC Form. The Primary Contact is
authorized to view, create, and enter data in the forms, and electronically certify, sign
and submit forms, on behalf of the Entity or Consortium.
This will auto-populate with the information listed within “Legal Entity Name” (Item #
4).
This is the mailing address, county, city, state, and zip code of the person who should
be contacted with questions about this request.
This is telephone number of the person who should be contacted with questions
about this request.
This is the email address of the person who should be contacted with questions about
this request.
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.
Optional. Allows the user to add additional contact person(s) to the request.
Additional contacts will have access to forms and be authorized to answer specific
questions about the applications associated with a funding request. They also be
authorized 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.
Optional. Provides an option for the user to upload and submit documents to support
their request.
4
OMB 3060-0804
X/XX/2023
Item #
Field Description
Purpose/Instructions
44
I certify under penalty of perjury that I am
authorized to submit this request on behalf of
the site or consortium.
45
I certify 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.
I understand that all documentation
associated with this request or demonstrating
compliance with the rules must be retained
for a period of at least five years after the last
day of service delivered in a particular funding
year pursuant to 47 CFR § 54.631, or as
otherwise prescribed by the Commission’s
rules.
If applying as an individual Health Care
Provider site, I certify under penalty of perjury
that the Health Care Provider is either a nonprofit, public entity or a dedicated ER of a
rural for-profit hospital.
If applying as an individual Health Care
Provider site, I certify under penalty of perjury
that the site is located in a designated rural
area, or was previously grandfathered as
rural.
Applicants are required to provide this certification in order to receive Healthcare
Connect Fund Program support. For individual Health Care Provider applicants,
certifications must be signed by an officer or director of the Health Care Provider or
other authorized employee of the Health Care Provider. For consortia applicants, an
officer, director, or other authorized employee of the Consortium Leader must sign
the required certification. The Authorized Person is required to provide all required
certifications and signatures.
See Item #44, Purpose/Instructions above.
46
47
48
See Item #44, Purpose/Instructions above
See Item #44, Purpose/Instructions above. Only applies to those applying as an
individual Health Care Provider site.
See Item #44, Purpose/Instructions above. Only applies to those applying as an
individual Health Care Provider site.
5
OMB 3060-0804
X/XX/2023
Item #
Field Description
Purpose/Instructions
See Item #44, Purpose/Instructions above. Only applies to those applying as a
consortium.
51
If applying as a consortium, I certify under
penalty of perjury that the eligible Health Care
Providers participating in the consortium are
either non-profit or public entities or
dedicated ER(s) of a rural for-profit hospital.
If applying as a consortium, I understand I
must obtain letters of agency (LOAs) 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.
Signature
52
Date Submitted
53
Date Signed
54
Authorized Person
55
Authorized Person’s Employer
56
Authorized Person’s Employer FCC
Registration Number
49
50
See Item #44, Purpose/Instructions above. Only applies to those applying as a
consortium.
The Authorized Person is required to provide all required certifications and
signatures. The request must be certified electronically.
Auto generated by system: This date is assigned based on the date the user submits
the FCC Form 460.
Auto generated by system: This date is assigned based on the date the user certifies
the FCC Form 460.
This is the name of the Authorized Person (either the Primary Contact or an
Additional Contact) that is certifying the FCC Form. This field will be auto-populated if
the name of the Authorized Person is already within the system.
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 certifying the FCC Form. This field will be autopopulated if already within the system.
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. This field will be autopopulated if already within the system.
6
OMB 3060-0804
X/XX/2023
Item #
Field Description
Purpose/Instructions
57
Authorized Person’s Title/Position
58
Authorized Person’s Mailing Address
59
Authorized Person Telephone Number
60
Authorized Person Email Address
61
Third Party Authorization (TPA)
62
Letter of Agency (LOA)
63
Letter of Exemption (LOE)
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 certifying the FCC Form. This field will be auto-populated if
already within the system.
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 certifying the FCC
Form. This field will be auto-populated if already within the system.
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 certifying the FCC Form. This field will be autopopulated if already within the system.
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 certifying the FCC Form. This field will be auto-populated if
already within the system.
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 Health Care
Provider or consortium.
For Consortia only. If applicable, the user must provide LOAs providing written
authorization to the Primary or Additional Contact(s) of a consortium to act on behalf
of each participating Health Care Provider or health system not owned or operated by
the consortium or organization operating the consortium.
For Consortia only. If applicable, the user must provide LOEs providing written
authorization to the Primary or Additional Contact(s) of a consortium to submit
requests for sites owned and operated by the consortium.
7
| File Type | application/pdf |
| Author | Catriona Ayer |
| File Modified | 2023-10-25 |
| File Created | 2023-10-05 |