FCC Form 465 RHC, Telecommunications Program, Description of Eligibil

NOT YET APPROVED BY OMB
Estimated time per response: 1hr

OMB 3060-0804
X/X/2023

Rural Health Care
Telecommunications Program
Description of Eligibility and Request for Services (FCC Form 465)
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 will be
carried forward and auto-populated into the form.

Item #
1

Field Description
FCC Form 465 Application Number

2

Applicant’s FCC Form Nickname

3
4

Site Name
Site Number

5

Site Address

6
7
8

Site Website
Site FCC Registration Number (FCC RN)
Employer Identification Number (EIN)

9
10

National Provider Identifier (NPI)
Organization Taxonomy Code

11

Site Taxonomy Code

12

Legal Entity Name

Purpose/Instructions
Auto generated by system. This is a unique Universal Service Administrative
Company (USAC)-assigned unique identifier for this request.
Optional. To create a unique identifier for this submission, the user simply enters a
nickname (e.g., Funding Year (FY) 2016 Homewood FCC Form 465).
This is the name of the site.
Auto generated by system. This is the unique USAC assigned identifier for the site
listed in Site Name.
This is the site’s physical address, county, city, state, zip code and geolocation.
Geolocation is an optional field that is only required for a site that does not have a
street address.
Optional. The website address of the site.
This is the site’s unique FCC RN identifier.
The EIN is also known as a Federal Tax Identification Number and is used to identify
a business or non-profit entity.
The ten-digit health care facility NPI that is 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.
If applicable. 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 Site
Name.
1

OMB 3060-0804
X/X/2023
Item #
13

Field Description
Legal Entity FCC RN

14

Legal Entity Contact

15

Consortium Name

16

Funding Year

17

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

18

Eligibility Entity Type that Requests Support

19

Eligibility Entity Type Requests Support: If
Consortium, Dedicated Emergency
Department or Part-Time Eligible Entity
Eligibility Entity Type that Seek Support: If
Community Mental Health Center

20

Purpose/Instructions
If applicable. This is the unique FCC identifier for the Legal Entity that owns and/or
operates the site.
This is the Legal Entity’s physical address, county, city, state, zip code, telephone,
website, contact name, email, phone number, contact employer and geolocation.
Geolocation only applies to a site that does not have a street address.
If applicable. User identifies as being a member of a larger collective group (e.g.
consortium, association, network, etc.) that participates in either the
Telecommunications or Healthcare Connect Fund Programs.
This is the selection of the FY the applicant is submitting the request for. Funding
years run from July 1 through June 30 of the following year. Available funding year
selections will be displayed by the system.
Optional. The user indicates whether they are using an RFP. If an RFP is used, it
must be attached to the FCC Form 465 so that it can be “released” with the posting
of the FCC Form 465 and the RFP period must be opened for at least 28 days after
the posting of the FCC Form 465.
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;
non-profit 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).
The user further describes the site if it qualifies as one of these types of sites.

If the user chooses “Community Mental Health Center,” then the user must submit
a Community Mental Health Center Certification, a copy of the health care
provider’s operating license.
2

OMB 3060-0804
X/X/2023
Item #
21

23

Field Description
Eligibility Entity Type Requests Support:
Additional Site Information
Eligibility Entity Type that Seek Support:
Additional Site Information
Services Requested: Category

24
25

Services Requested: Type
Number of Months of Service Requested

26
27
28

Symmetrical Service
Upload Speed
Download Speed

29

Service Level Agreement (SLA)

30
31
32
33
34

Latency
Jitter
Packet Loss
Reliability
Services Requested: Additional Service
Details

35
36

Services Requested: Desired Contract Length
Services Requested: Bid Posting Period

22

Purpose/Instructions
Optional. The user has the ability to provide a brief explanation of why the site
qualifies as the category selected.
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 Tribe.
The user identifies the service category for which the site is requesting bids (e.g.,
voice, data).
The user identifies the service type for which the site is requesting bids (e.g., T-1).
The user indicates the number of months of service that is being requested for the
service.
The user indicates if the upload and download speeds must be equal.
The user enters the requested upload speed for the service.
If the service is not symmetrical, the user enters the requested download speed for
the service.
Optional. The user indicates whether it is seeking an SLA as part of the agreement
with the selected service provider.
The user indicates the latency requirement for the SLA.
The user indicates the jitter requirement for the SLA.
The user indicates the packet loss rate for the SLA.
The user indicates the reliability requirements for the SLA.
The user describes additional details regarding the services for which it is
requesting bids. The user shall provide sufficient information to enable bidders to
reasonably determine the needs of the user and provide responsive bids.
The user provides details on the length and type of contract requested.
Optional. The user may add days on to the posting period beyond the required
minimum 28-day posting period.

3

OMB 3060-0804
X/X/2023
Item #
37

Field Description
Bidding Evaluation

38

Primary Contact Name

39
40

Primary Contact Employer/Organization
Primary Contact Title

41

Primary Contact Mailing Address

42

Primary Contact Telephone Number

43

Primary Contact Email Address

44

Primary Contact Fax Number

45

Additional Contact(s)

Purpose/Instructions
The user develops 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. “Cost-effective” is defined as the method that
costs the least after consideration of the features, quality of transmission,
reliability, and other factors that the health care provider deems relevant to
choosing a method of providing the required health care services. 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.
This is the name of the person who should be contacted with questions about this
request. This person must be employed by the Legal Entity listed on this form.
This will auto-populate to be the information listed within “Legal Entity Name.”
This is the title of the person who should be contacted with questions about this
request.
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 the 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.
This is the fax number of the person who should be contacted with questions about
this request.
Allows the user to add additional contact person(s) to the request. 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). This person will be an account holder in MyPortal with access to
the site’s application forms.

4

OMB 3060-0804
X/X/2023
Item #
46

Field Description
Aggregated Purchasing Agreement

Purpose/Instructions
Optional. If applicable, user shall provide full details of any arrangement involving
the purchasing of service/s as part of an aggregated purchase with other entities or
individuals. User may also upload and submit any other supporting documents to
support its request.

47

Declaration of Assistance/Consultant or
Outside Expert Information

48

Letter of Authorization

49

Supporting Documentation

50

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

51

If applicable. Users must submit a declaration of assistance identifying each and
every consultant, vendor, or other outside expert, whether paid or unpaid, who
aided in the preparation of their applications and, as part of this declaration, users
must describe the nature of their relationship with the consultant, vendor, or other
outside expert providing the assistance. The user must provide the name of the
consultant’s or outside expert’s firm name; consultant registration number; name
of the consultant or outside expert representing the applicant; consulting firm
street address, city, state, and zip code; consulting firm telephone number; and
consulting firm email address. If this information has already been entered into the
user’s profile, it will be pre-populated into the system.
If applicable, the user must provide a letter of authorization which provides written
authorization to a third party/consultant to complete and submit FCC Forms on
behalf of the health care provider for the Telecommunications Program.
Optional. This provides an option for the user to upload and submit any other
documents to support their request.
The Authorized Person is required to provide all required certifications and
signatures. An officer or director of the applicant must sign all certifications. The
applicant must provide this certification in order to receive universal service
support.
See Item #50 Purpose/Instructions above.

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
See Item #50 Purpose/Instructions above.
applicant has complied with all applicable
state, Tribal, or local procurement rules.

52

5

OMB 3060-0804
X/X/2023
Item #
53

54

55

56

57

58

Field Description
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 applicant 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
supported 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 is a
public or non-profit entity that falls within
one of the categories set forth in the
definition of health care provider listed in 47
CFR § 54.600 of the Commission’s rules.
I certify under penalty of perjury that the
applicant seeking support services is
physically located in a rural area as defined
in section 47 CFR § 54.600 of the
Commission’s rules.
I certify under penalty of perjury that the
applicant satisfies all of the requirements
under section 254 of the Communications
Act and applicable Commission rules.
I certify under penalty of perjury that the
applicant has reviewed and will comply with
all applicable RHC Program requirements.

Purpose/Instructions
See Item #50 Purpose/Instructions above.

See Item #50 Purpose/Instructions above.

See Item #50 Purpose/Instructions above.

See Item #50 Purpose/Instructions above.

See Item #50 Purpose/Instructions above.

See Item #50 Purpose/Instructions above.

6

OMB 3060-0804
X/X/2023
Item #
59

60
61
62
63

Field Description
I understand that all documentation
associated with this request 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

64

Authorized Person’s Employer

65

Authorized Person’s Employer FCC RN

66

Authorized Person’s Title/Position

67

Authorized Person’s Mailing Address

68

Authorized Person Telephone Number

69

Authorized Person Email Address

Purpose/Instructions
See Item #50 Purpose/Instructions above.

The FCC Form 465 must be certified electronically.
Auto generated by system.
Auto generated by system.
The Authorized Person is required to provide all required signatures and
certifications. The FCC Form 465 must be certified electronically. 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
465. This field will be auto-populated if already within the system.
This is the FCC RN of the Authorized Person certifying the FCC Form 465. This field
will be auto-populated if already within the system.
This is the title of the Authorized Person certifying the FCC Form 465. 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 465. This field will be auto-populated if already
within the system.
This is the telephone number of the Authorized Person certifying the FCC Form 465.
This field will be auto-populated if already within the system.
This is the email address of the Authorized Person signing the FCC Form 465. This
field will be auto-populated if already within the system.

7