FCC Form 465 Rural Health Care Universal Service Mechanism

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Overview

Blocks 1-5
Block 6, Reminder & Disclaimer

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Sheet 1: Blocks 1-5

FCC Form

Health Care Providers Universal Service

Approval by OMB

465

Description of Services Requested & Certification Form

3060—0804

Estimated time per response: 1 hour

Read instructions thoroughly before completing this form. Failure to comply may cause delayed or denied funding.

Form 465 Application Number (assigned by RHCD)

Block 1: HCP Location Information

Information required in this block applies to the physical location of the HCP. Do not enter a "PO Box" or "Rural Route" address.

1

HCP Number

2

Consortium Name

3

HCP Name

4

HCP FCC Registration Number (FCC RN)

5

Contact Name

6

Address Line 1

7

Address Line 2

8

County

9

City

10

State

11

ZIP Code

12

Phone #

13

Fax #

14

E-mail

Block 2: HCP Mailing Contact Information

15

Is the HCP’s mailing address (where correspondence should be

Yes, complete Block 2

sent) different from its physical location described in Block 1?

No, go to Block 3.

16

Contact Name

17

Organization

18

Address Line 1

19

Address Line 2

20

City

21

State

22

ZIP Code

23

Phone #

24

Fax #

25

E-mail

Block 3: Funding Year Information

26

Funding Year (Check only one box)

Year 2009 (7/1/2009-6/30/2010)

Year 2010 (7/1/2010-6/30/2011)

Year 2011 (7/1/2011-6/30/2012)

Year 2012 (7/1/2012-6/30/2013)

Block 4: Eligibility

27

Only the following types of HCPs are eligible. Indicate which category describes the applicant. (Check only one.)

Post-secondary educational institution offering health care

Rural health clinic

instruction, teaching hospital or medical school

Community health center or health center providing health

Consortium of the above

care to migrants

Local health department or agency

Dedicated ER of rural, for-profit hospital

Community mental health center

Not-for-profit hospital

Part-time eligible entity

28

If consortium, dedicated emergency department, or part-time eligible entity was selected in Line 27, please describe the entity.

29

Please describe the eligible health care provider's telecommunications and/or Internet service needs, so that service providers

may bid to provide the services. The description should describe whether video or store and forward consultations will be

used, whether large image files or X-rays will be transmitted, the quality of connection needed, or other relevant considerations.

Block 5: Request for Services

30

Is the HCP requesting reduced rates for:

Both Telecommunications & Internet Services

Telecommunications Service ONLY

Internet Service ONLY

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Sheet 2: Block 6, Reminder & Disclaimer

Block 6: Certification

31

I certify that I am authorized to submit this request on behalf of the above-named entity or entities, that I have examined this request,

and that to the best of my knowledge, information, and belief, all statements of fact contained herein are true.

32

I certify that the health care provider has followed any applicable State or local procurement rules.

33

I certify that the telecommunications services and/or Internet access charges that the HCP receives at reduced rates as a result of the

HCPs' participation in this program, pursuant to 47 U.S.C. Sec. 254 as implemented by the Federal Communications Commission,

will be used solely for purposes reasonably related to the provision of health care service or instruction that the HCP is legally

authorized to provide under the law of the state in which the services are provided and will not be sold, resold, or transferred

in consideration for money or any other thing of value.

34

I certify that the health care provider is a non-profit or public entity.

35

I certify that the health care provider is located in a rural area. Visit the RHCD website:

(http://www.usac.org/rhc/tools/rhcdb/Rural/2005/search.asp) or contact RHCD at 1-800-229-5476 for a listing of rural areas.

36

Pursuant to 47 C.F.R. Secs. 54.601 and 54.603, I certify that the HCP or consortium that I am representing satisfies all of the

requirements herein and will abide by all of the relevant requirements, including all applicable FCC rules, with respect to funding

provided under 47 U.S.C. Sec. 254.

37

Signature

38

Date

39

Printed name of authorized person

40

Title or position of authorized person

41

Employer of authorized person

42

Employer's FCC RN

Please remember:

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Form 465 is the first step a health care provider must take in order to receive the benefit of reduced rates resulting from

participation in this universal service support program.

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After the HCP submits a complete and accurate Form 465, the RHCD will post it on the RHCD web site for 28 days.

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HCPs may not enter into agreements to purchase eligible services from service providers before the 28 days expire.

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After the HCP selects a service provider, the HCP must initiate the next step in the application process, the filing of Form 466 and/or 466A.

Persons willfully making false statements on this form can be punished by fine or forfeiture under the Communications Act, 47 U.S.C. Secs. 502,

503(b), or fine or imprisonment under Title 18 of the United States Code, 18 U.S.C. Sec. 1001.

FCC NOTICE FOR INDIVIDUALS REQUIRED BY THE PRIVACY ACT AND THE PAPERWORK REDUCTION ACT

Part 3 of the Commission's Rules authorize the FCC to request the information on this form. The purpose of the information is to determine your

eligibility for certification as a health care provider. The information will be used by the Universal Service Administrative Company and/or the

staff of the Federal Communications Commission, to evaluate this form, to provide information for enforcement and rulemaking proceedings and

to maintain a current inventory of applicants, health care providers, billed entities, and service providers. No authorization can be granted unless

all information requested is provided. Failure to provide all requested information will delay the processing of the application or result in the

application being returned without action. Information requested by this form will be available for public inspection. Your response is required

to obtain the requested authorization.

The public reporting for this collection of information is estimated to average 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 (3060-0804), 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 pra@fcc.gov. PLEASE DO NOT

SEND YOUR RESPONSE 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 PRIVACY ACT OF 1974, PUBLIC LAW 93-579, DECEMBER 31, 1974, 5 U.S.C. 552a(e)(3)

AND THE PAPEWORK REDUCTION ACT OF 1995, PUBLIC LAW 104-13, OCTOBER 1, 1995, 44 U.S.C. SECTION 3507.

This form should be submitted to:

Rural Health Care Division

30 Lanidex Plaza West, P.O.Box 685

Parsippany NJ 07054-0685