FCC Form 461 RHC, HFCP, Description of Request for Services

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Estimated time per response: 2hrs

OMB 3060-0804
X/X/2023

Rural Health Care
Healthcare Connect Fund Program
Description of Request for Services (FCC Form 461)
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 #
1

Field Description
Applicant’s FCC Form Nickname

2
3

Funding Year
FCC Form 461 Application Number

4

FCC Form 460 Number

5

FCC Form 461 Posting Start Date

6

FCC Form 461 Posting End Date

7

Allowable Contract Selection Date (ACSD)

8
9

Site Name
Site Number

10

Site Address

Purpose/Instructions
Optional. To create a unique identifier for this request, the user simply enters a
nickname (e.g., 2016 Funding Year Homewood FCC Form 461).
This is the selection of the funding year the applicant is submitting the request for.
Auto-generated by the system: This is a unique Universal Service Administrative
Company (USAC)-assigned identifier for this request.
Auto-generated by the system: Based on information for the previously submitted
Description of Eligibility (FCC Form 460). This is a USAC-assigned unique identifier for
this request.
Auto-generated by the system: This is a USAC-assigned date based on the date of
submission of the request and review of the request.
Auto-generated by the system: This is a USAC-assigned date based on no less than 28
days from the FCC Form 461 posting start date.
Auto-generated by the system: This is a USAC-assigned date, plus any time added by
the user, after which the applicant is able to enter into an agreement with a service
provider. This date must be a date after the RFP and/or FCC Form 461 posting end
date.
Auto-populated by the system: This is the site name submitted on the FCC Form 460.
Auto-populated by the system: This is the unique USAC-assigned identifier for this site
listed in Site Name on the FCC Form 460.
Auto-populated by the system: This is the site’s physical address, county, city, state,
zip code, and geolocation submitted on the FCC Form 460. Geolocation only applies to
a site that does not have a street address.
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Item #
11

Field Description
Consortium Name

12

Consortium Number

13

Consortium Address

14

FCC Registration Number

15

Indicate Whether a Separate Request for
Proposals (RFP) will be Released for this
Request

16

Letter of Agency (LOA)

17

Network Plan

18

Services and/or Equipment Requested:
Category
Services and/or Equipment Requested: Service
Details

19

20
21
22

Services and/or Equipment Requested: Site(s)
Listing
Services and/or Equipment Requested:
Desired Contract Length
Services and/or Equipment Requested: Bid
Evaluation Period

Purpose/Instructions
Auto-populated by the system: This is the name the consortium submitted on the FCC
Form 460.
Auto-populated by the system: This is the unique USAC-assigned identifier for
consortium listed in Site Name on the FCC Form 460.
Auto-populated by the system: This is the consortium’s address, county, city, state,
zip code and geolocation submitted on the FCC Form 460. Geolocation only applies to
a consortium that does not have a street address.
Auto-populated by the system: This is either the consortium or the site’s unique FCC
registration number submitted via the FCC Form 460.
The user indicates whether they are issuing an RFP for the requested services. If an
RFP is used, it must be attached to the FCC Form 461 so that it can be “released” with
the posting of the FCC Form 461 and the RFP must be opened for at least 28 days
after the posting of the FCC Form 461.
For consortia only. The Consortium Leader is required to submit an LOA for each
eligible health care provider participating in the consortium no later than when it
submits its Request for Services (FCC Form 461).
For consortia only. If an applicant is a consortium, they must submit a narrative of its
Network Plan with the FCC Form 461.
The user identifies the services and/or equipment for which the site is requesting
bids (e.g., Internet access).
The user describes the services and/or equipment for which it is requesting bids (e.g.,
minimum download/upload speed needs, maximum download/upload speed that will
be considered, needed functionality of equipment, how the services will be used,
quantity of the product or service sought, requested pricing ranges). The user shall
provide sufficient information to enable bidders to reasonably determine the needs of
the user and provide responsive bids.
The user provides information on the sites/entities included in the request.
The user provides details on the length and type of contract requested.
Optional. The user can express how long after the end of the FCC Form 461 28-day
posting period they will need to evaluate bids. The expected bid evaluation period is
not part of the ACSD calculation.
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Item #
23

Field Description
Services and/or Equipment Requested: USAC
Bid Posting Period

24

Bidding Evaluation

25

Aggregate Purchasing Arrangement

26

Supporting Documentation

27

Contact Person Name

28

Contact Person Employer

29

Contact Person Title

30

Contact Person Mailing Address

31

Contact Person Telephone Number

32

Contact Person Email Address

Purpose/Instructions
Optional. The user may add days to the posting period beyond the required minimum
28-day posting period. The system will only allow the applicant to enter a date that
meets or exceeds the 28-day minimum requirement.
The user develops a weighted evaluation criteria (e.g., scoring matrix) that
demonstrates how the applicant will choose the most ‘cost-effective' bid before
submitting a request for services. Price must be a primary factor, but need not be the
only primary factor. A non-price factor can receive an equal weight to price, but may
not receive a greater weight than price. The user must specify on their bid evaluation
worksheet and/or scoring matrix the requested services for which it seeks bids, the
information provided to bidders to allow bidders to reasonably determine the needs
of the user, its minimum requirements for each specified criterion, and each service
provider’s proposed service levels for the established criteria. The user must also
specify its disqualification factors, if any, that the user will use to remove bids or
bidders from further consideration.
Optional. If the user has an aggregate purchasing arrangement, the user shall provide
full details of any arrangement involving the purchasing of a service or services and/or
equipment as part of an aggregated purchase with other entities or individuals.
Optional. Users may also upload and submit any other supporting documents to
support their request.
The user must provide the name of the person who should be contacted with
questions about this request. This could be the Primary Contact, Additional Contact(s)
or another person qualified to answer questions relating to the request.
The user must provide the employer of the person who should be contacted with
questions about this request.
The user must provide the title of the person who should be contacted with questions
about this request.
The user must provide the mailing address of the person who should be contacted
with questions about this request.
The user must provide the telephone number of the person who should be contacted
with questions about this request.
The user must provide the email address of the person who should be contacted with
questions about this request.
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Item #
33

Field Description
Contact Person Fax Number

34

Declaration of Assistance/Consultant or
Outside Expert Information

35

I certify under penalty of perjury that I am
authorized to submit this request on behalf of
the health care provider or consortium.

36

I certify under penalty of perjury that I have
examined this request and all attachments,
and to the best of my knowledge, information,
and belief, all statements contained herein
and in any attachments are true.
I certify under penalty of perjury that the
applicant seeking supported services is a
nonprofit or public entity that falls within one
of the seven categories set forth in the
definition of health care provider listed in 47
CFR §54.600 of the Commission’s rules.

37

Purpose/Instructions
The user must provide the fax number of the person who should be contacted with
questions about this request.
If applicable. If the user uses a consultant, service provider, or any other outside
expert, whether paid or unpaid, who aided in the preparation of its request and/or
RFP, the user must provide the name of the company, name of the person
representing the applicant, title of the person representing the applicant, telephone
number, email address, and physical address. The user must also describe the nature
of the relationship it has with any consultant, vendor, or other outside expert
identified in its declaration of assistance.
The Authorized Person is required to provide all certifications and signatures. For
individual applicants, certifications must be signed by an officer or director of the
applicant. For consortium applicants, an officer, director, or other authorized
employee of the Consortium Leader must sign the required certification. The
applicant is required to provide this certification in order to receive universal service
support.
See Item #35 Purpose/Instructions above.

See Item #35 Purpose/Instructions above.

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Item #
38

39

40

41

42

43

Field Description
I certify under penalty of perjury that the
applicant seeking supported services is
physically located in a rural area as defined in
section 47 CFR § 54.600 of the Commission’s
rules, or is a member of a consortium which
satisfies the majority-rural composition
requirements set forth in 47 CFR § 54.607 of
the Commission’s rules.
I certify under penalty of perjury that the
applicant seeking supported services has
complied with any applicable state, Tribal, or
local procurement rules.
I certify under penalty of perjury that all
requested RHC Program support will be used
solely for purposes reasonably related to the
provision of health care service or instruction
that the health care provider is legally
authorized to provide under the law of the
state in which the services are provided.
I certify under penalty of perjury that the
services will not be sold, resold, or transferred
in consideration for money or any other thing
of value.
I certify under penalty of perjury that the
applicant seeking supported services satisfies
all of the requirements under section 254 of
the Communications Act, 47 U.S.C. § 254, and
applicable Commission rules.
I certify under penalty of perjury that the
applicant seeking support has reviewed and is
compliant with all applicable RHC Program
requirements.

Purpose/Instructions
See Item #35 Purpose/Instructions above.

See Item #35 Purpose/Instructions above.

See Item #35 Purpose/Instructions above.

See Item #35 Purpose/Instructions above.

See Item #35 Purpose/Instructions above.

See Item #35 Purpose/Instructions above.

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Item #
44

45
46
47
48

Field Description
I understand that all documentation
associated with this request, including a copy
of the signed Request for Services (FCC Form
461), any bids/contracts resulting from the
FCC Form 461 posting, scoring sheet, and
other information that was used in the
decision making process, must be retained for
a period of at least five years pursuant to 47
CFR § 54.631, or as otherwise prescribed by
the Commission’s rules.
Signature
Date Submitted
Date Signed
Authorized Person Name

49

Authorized Person’s Employer

50
51

Authorized Person’s Employer FCC
Registration Number
Authorized Person’s Title/Position

52

Authorized Person’s Mailing Address

53

Authorized Person Telephone Number

54

Authorized Person Email Address

Purpose/Instructions
See Item #35 Purpose/Instructions above.

The FCC Form 461 must be signed electronically.
Auto generated by system.
Auto generated by system.
The Authorized Person is required to provide all required certifications and signatures.
This is the name of the Authorized Person certifying the FCC Form 461. This field will
be auto-populated if the name of the Authorized Person is already within the system.
This is the name of the employer of the Authorized Person certifying the FCC Form
461. This field will be auto-populated if already within the system.
This is the FCC registration number of the Authorized Person certifying the FCC Form
461. This field will be auto-populated if already within the system.
This is the title of the Authorized Person certifying the FCC Form 461. This field will be
auto-populated if already within the system.
This is the address (can be physical address or mailing address) of the Authorized
Person certifying the FCC Form 461. This field will be auto-populated if already within
the system.
This is the telephone number of the Authorized Person certifying the FCC Form 461.
This field will be auto-populated if already within the system.
This is the email address of the Authorized Person certifying the FCC Form 461. This
field will be auto-populated if already within the system.

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