DR AF T New FCC Form 460 Rural Health Care (RHC) Universal Service Eligibility and Registration Form Subject to Approval by OMB 3060-0804 Estimated time per response: 1 hour Read instructions thoroughly before completing this form. Failure to comply may cause delayed or denied funding. Block 2: Physical Location Enter the actual physical location of the HCP site. 3 HCP Number 4 Site Name 5 Name of Legal Entity 6 FCC Registration Number (FCC RN) 7 Site Contact Name 8 Address Line 1 9 Address Line 2 10 County 11 GeoLocation (optional) 12 City 13 State 14 Zip Code 15 Phone Ext. 16 Email Block 3: Consortium Information 17 HCP Number 18 Name of Consortium 19 Is the Consortium a legal entity? Yes No If yes, Consortium FCC RN: 20 Consortium has a written agreement allocating legal and financial responsibility. Yes No If yes, submit the agreement to USAC. If no, see instructions regarding the default entity that bears legal and financial responsibility for the consortium’s activities in connection with the Healthcare Connect Fund. 21 Consortium Leader Type: The Consortium An eligible HCP participating in the Consortium HCP Number: ________________________ Ineligible State organization Ineligible public sector (government) entity Ineligible non-profit entity A state organization, public sector entity, or non-profit entity may obtain an exemption to allow the organization to perform vendor functions and provide application assistance. Submit any such request for exemption. 22 Consortium Leader Contact Information 23 Name of Consortium Leader Consortium applicants are required to have a Letter of Agency from each eligible HCP that authorizes the Consortium to file forms on the HCP’s behalf. Submit a Letter of Agency for each eligible HCP. 24 List participating sites by HCP Number (eligible/ineligible) Block 4: Contact Information 25 Primary Account Holder/Project Coordinator Name 26 Employer 27 Address Line 1 Same as Physical Location 28 Address Line 2 29 City 30 State 31 Zip Code 32 Phone # Ext. 33 Email 34 Secondary Account Holder (Application Contact/Assistant Project Coordinator) Block 1: General Information 1 Date Submitted: 2 Applying to: Determine eligibility of an HCP site Determine eligibility of Consortium Register an off-site data center Register an ineligible site Register an off-site administrative office 2a If applying as an off-site data center, list all sites (eligible and ineligible) that will use the services of this data center. 2b If applying as an off-site administrative office, list all sites (eligible and ineligible) that will use the services of this administrative office. DR AF T Block 5: Eligibility Category (Only complete if HCP site is seeking support) 43 Select the category that describes the HCP site: A. Community health center or health center providing health care to migrants B. Community mental health center C. Local health department/agency D. Non-profit hospital E. Part-time eligible entity located in an ineligible facility F. Post-secondary educational Institution offering health care instruction, teaching hospital, or medical school G1. Rural health clinic G2. Is this a mobile rural health care provider? Yes No H. Dedicated ER of rural, for-profit hospital I. Consortium of the above 44 Provide a brief explanation of why this site qualifies as the organization type selected above: FCC Form 460 Block 6: Additional Information 45 Non-Profit Tax ID (EIN): 46 National Provider Identifier: 47a Organization Taxonomy Code: Explanation if necessary (see instructions) 47b Site Taxonomy Code: Explanation if necessary (see instructions) 48 If a Non-Profit Hospital, is this a Critical Access Hospital? Yes No 49 If a Non-Profit Hospital, how many licensed patient beds are at the site? _______________ 50 Is the site location: On Tribal lands Otherwise affiliated with a Tribe Operated by the Indian Health Service N/A 51 [Reserved] 52 [Reserved] Block 7: Certifications and Signatures 53 I certify that I am authorized to submit this request on behalf of the site or consortium. 54 I declare under penalty of perjury that I have examined this form and attachments and to the best of my knowledge, information, and belief, all information contained in this form and in any attachments is true and correct. 55 If applying as an individual health care provider site, I certify that the health care provider is a non-profit or public entity and that the site is located in a FCC designated rural area, or is grandfathered rural pursuant to 47 C.F.R. Sec. 54.600(b)(2). 56 If applying as a consortium, I certify that the eligible health care providers participating in the consortium are non-profit or public entities. 57 I understand that all documentation associated with this form must be retained for a period of at least five years pursuant to 47 C.F.R. § 54.648, or as otherwise prescribed by the Commission’s rules. 58 If applying as a consortium, I understand I must obtain letters of agency from each consortium member that grants me the authority to complete, sign, and submit all forms for the funding year(s) for which support is sought. 59 Signature 60 Date 61 Printed Name of Authorized Person Block 2: Physical Location 35 Employer 36 Address Line 1 Same as Primary Account Holder Address 37 Address Line 2 38 City 39 State 40 Zip Code 41 Phone # Ext. 42 Email DR AF T FCC Form 460 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. Block 7: Certifications and Signatures 62 Title/Position of Authorized Person 63 Phone Ext. 64 Email 65 Employer 66 Employer’s FCC RN