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Commission Document Attachment

Subject to Approval by OMB
3060-0804
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FCC Form 461 Instructions

Rural Health Care (RHC) Universal Service
Healthcare Connect Fund
Request for Services Form
I.
PURPOSE OF FORM......................................................................................................... 2
II.
FILING REQUIREMENTS AND GENERAL INSTRUCTIONS ............................................. 2
A. Who must file................................................................................................................... 2
B. When to file ..................................................................................................................... 3
C.
Where to file................................................................................................................. 4
D.
Next Steps ................................................................................................................... 4
E. Modifications to the Form 461 and Associated Documents.............................................. 4
F. For More Information....................................................................................................... 5
III.
SPECIFIC INSTRUCTIONS FOR FILING FORM 461 ..................................................... 5
A. Block 1: General Information .......................................................................................... 5
B. Block 2: Individual HCP Site Request for Services ......................................................... 5
C.
Block 3: Consortium Request for Services .................................................................. 6
D.
Block 4: Declaration of Assistance (to be completed by all applicants)........................ 8
E. Block 5: Bid Evaluation (to be completed by all applicants) ............................................ 8
F. Block 6: Additional Documentation (to be completed by all applicants)........................... 8
G.
Block 7: Certifications ................................................................................................. 9
IV.
REMINDERS..................................................................................................................10
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I. PURPOSE OF FORM

Submitting the Federal Communications (FCC) Form 461 is the second step an individual health
care provider (HCP) or consortium must take to participate in the universal service support
mechanism’s Healthcare Connect Fund (Fund). Submitting the Form 460, which enables USAC
to determine whether an HCP site is eligible for support, is the first step.
Unless they are exempt from the competitive bidding requirement (as described below in Who
Must File
), all entities participating in the Healthcare Connect Fund must complete the
competitive bidding process before submitting a funding request (the third step, Form 462). To
initiate the competitive bidding process, applicants must submit a request for services (Form
461), which must be posted on USAC’s website for no less than 28 days. The purpose of the
Form 461 and supporting documentation is to provide sufficient information about the requested
services, network equipment, and/or facilities to enable an effective competitive bidding
process, and to provide the Universal Service Administrative Company (USAC) with the
required certifications and other information necessary to prevent waste, fraud, and abuse.
Applicants may seek funding (by filing a Form 462) only after the competitive bidding process is
complete.
The required FCC Form 460(s) must be filed prior to or with the filing of the FCC Form 461. An
applicant is encouraged to file its required Form 460(s) at least 30 days prior to filing a request
for services (Form 461). Certain information will carry over (“auto-populate”) from FCC Form
460 to Form 461, so make sure that all of the Form 460(s) for consortia and sites that will be
listed on the Form 461 are up to date before starting Form 461. Applicants are cautioned that
the Form 461 will not be posted on USAC’s site until USAC has confirmed eligibility of the HCP
site(s) for which support is sought.
Applicants must file all forms with USAC, not the FCC. See Where to File below for more
information.
All applicants are encouraged to review the FCC’s Healthcare Connect Fund Order, FCC 12-
150, available at http://hraunfoss.fcc.gov/edocs_public/attachmatch/FCC-12-150A1.pdf">http://hraunfoss.fcc.gov/edocs_public/attachmatch/FCC-12-150A1.pdf, and the
FCC’s rules at 47 C.F.R. § 54.600 et seq., available at http://www.ecfr.gov/">http://www.ecfr.gov.

II. FILING REQUIREMENTS AND GENERAL INSTRUCTIONS

When submitting a completed Form 461, the applicant should include, if applicable, a legal and
financial responsibility agreement (consortium applicant), bid evaluation criteria, request for
proposals (RFP), network plan (consortium applicant), letters of agency (consortium applicant)
and declarations of assistance. Information about the additional documentation is provided in
the specific Block and Line instructions below.

A. Who must file

All applicants are required to file the FCC Form 461 unless their request for services meets one
or more of the competitive bidding exemptions listed below. If an applicant is only exempt for a
portion of the funding year, the applicant must file a Form 461 and go through the competitive
bidding process to receive funding for the remainder of the funding year. If an applicant is
unsure as to whether it must file the FCC Form 461, contact RHC at 1-800-453-1546 or rhc-
assist@usac.org for assistance.
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Competitive bidding exemptions: Certain applicants seeking support from the Fund are exempt
from the competitive bidding process and not required to file a Form 461. After completing the
Form 460 process, exempt applicants may proceed directly to filing the request for funding on
Form 462. Below are the competitive bidding exemptions. See 47 C.F.R. § 54.642(h).
 Annual Undiscounted Cost of $10,000 or Less: Applicants seeking support for $10,000
or less of total undiscounted eligible expenses for a single year (i.e. up to $6,500 in Fund
support) are exempt from the competitive bidding requirements. The exemption does
not apply to multi-year contracts. Under this exemption, an applicant is restricted to a
total of $6,500 in annual Fund support for services that are not subject to another
exemption. Services supported through the Telecommunications Program are not
counted toward the $10,000 limit.
 Government Master Service Agreements (MSAs): Applicants who are purchasing
services and/or network equipment from an MSA negotiated by federal, state, Tribal, or
local government entities on behalf of such HCPs and others, are exempt from the
competitive bidding requirements, but only if such MSAs were awarded pursuant to
applicable federal, state, Tribal, or local competitive bidding requirements. This
exemption only applies to MSAs that were negotiated by, or under the direction of,
government entities and that were subject to government competitive bidding
requirements.
 MSA Approved under the RHC Pilot Program or Healthcare Connect Fund: Applicants
purchasing services and/or network equipment from MSAs previously approved by
USAC under the RHC Pilot Program or the Healthcare Connect Fund are exempt from
competitive bidding. The exemption is limited to those MSAs that were developed and
negotiated from an RFP or request for services that specifically sought a mechanism to
add additional sites to the network.
 Evergreen Contracts: Applicants purchasing services from a contract already designated
by USAC as “evergreen” are exempt from the competitive bidding process.
 E-Rate Approved Contracts: Applicants who enter into consortia with E-rate (Schools
and Libraries Program) participants under 47 C.F.R. § 54.501(c)(1) and are purchasing
services and/or network equipment from a master contract approved under the E-rate
program are exempt from the competitive bidding process.
Applicants who do not meet one or more of the exemptions above are required to complete and
submit this form and associated documents to USAC. Learn more about the competitive
http://www.usac.org/rhc/healthcare-connect/default.aspx">bidding process at: http://www.usac.org/rhc/healthcare-connect/default.aspx.

B. When to file

Applicants may submit the Form 461 starting 180 days before the beginning of the funding year,
which starts on July 1. To allow sufficient time to complete the competitive bidding process,
select a vendor, and have services started on or before the first day of the funding year
(allowing for a full year of support), applicants should submit this form and all supporting
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documentation as soon as possible. Applicants may of course also request funding for less
than a full funding year.

C. Where to file

Applicants must submit all forms electronically through USAC’s RHC My Portal website at
https://forms.universalservice.org/usaclogin/login.asp" title="https://forms.universalservice.org/usaclogin/login.asp">https://forms.universalservice.org/usaclogin/login.asp. Instructions on how to file electronically
may be http://www.usac.org/rhc/healthcare-connect/default.aspx">found at USAC’s RHC website at: http://www.usac.org/rhc/healthcare-
connect/default.aspx.
Do not file this or any other forms for the RHC program with the FCC.

D. Next Steps

After the Form 461 is submitted and processed, USAC will post the Form 461 and supporting
documentation on the RHC website for potential vendors to review and provide bids for the
requested services, network equipment, and/or facilities. After the form is posted, USAC will
send confirmation of the posting to the applicant, including the posting date and the Allowable
Contract Selection Date (ACSD). Unless covered by a competitive bidding exemption, an
applicant must wait at least until its ACSD before it agrees to or signs a contract with a vendor.
An applicant may not agree to or sign a contract with a vendor until after the ACSD, but may
discuss requirements, rates, and conditions with potential vendors prior to that date. Applicants
who sign a service agreement or contract before the ACSD are not eligible for funding.
Applicants may extend the time period for receiving bids beyond the required minimum 28 days
from the posting of the Form 461 without prior approval from USAC. If an applicant would like to
post the Form 461 for longer than 28 days, it must indicate that the posting period is longer than
28 days on the Form 461. An applicant can also decide to extend the bidding period after
USAC has posted the Form 461 by notifying USAC and requesting that USAC update its web
site with notice of the extension. USAC will also revise the ACSD to reflect the extended
bidding period. Once an applicant has extended the bidding period, it cannot be shortened.

E. Modifications to the Form 461 and Associated Documents

All potential bidders and service providers must have access to the same information and must
be treated in the same manner. Any additions or modifications to the documents submitted to,
and posted by, USAC must be made available to all potential service providers at the same time
and using a uniform method. This does not prohibit applicants from seeking additional
information about particular products or services during the competitive bidding process, or
potential vendors from supplying it. All applicants who utilize an RFP in conjunction with their
competitive bidding process must provide USAC with any subsequent changes to the RFP.
USAC will facilitate this process by allowing applicants to submit any additions or modifications
to USAC, for posting on the same web page as the originally posted documents. If an applicant
makes any changes to its RFP post-submission, it is responsible for ensuring that USAC has a
current version of the RFP for the web site posting. Any modification or change to the
competitive bidding documents will reset the competitive bidding period and push back the
ACSD.
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F. For More Information

Contact the USAC RHC Help Desk at 1-800-453-1546 between 9:00 a.m. and 6:00 p.m. EST,
Monday through Friday or email at rhc-assist@usac.org.

III. SPECIFIC INSTRUCTIONS FOR FILING FORM 461

A. Block 1: General Information

Requires basic applicant information.

Line 1:

Enter the funding year for which support is sought. For a multi-year funding request,
enter the first funding year for which funding is requested. A funding year run from July 1 to
June 30 (thus, funding year 2014 begins on July 1, 2014).

Line 2:

Enter the applicant’s HCP Number, assigned by USAC when the Form 460 is
submitted.

Line 3:

The consortium name (or, HCP name, if participating individually) will be auto-
populated based on the HCP Number entered in Line 2. If the name is incorrect, the applicant
must submit an updated Form 460.

Lines 4-9:

The address, county, city, state and zip code of the consortium (or, HCP, if
participating individually) will also be auto-populated based on the HCP Number entered in Line
2. If any of this information is inaccurate, the applicant must submit an updated Form 460.

B. Block 2: Individual HCP Site Request for Services

Only complete lines 10-13 if applying as an individual HCP site.

Line 10:

Requires the applicant to indicate whether it has prepared and is submitting an RFP
with the Form 461. See Additional Documentation in Block 6 below for information about when
an RFP must be submitted. If an applicant makes any changes to its RFP post-submission, it is
responsible for ensuring that USAC has a current version of the RFP for the web site posting.

Line 10a:

If the applicant is not submitting an RFP, indicate the expected dates of service.

Line 10b:

If the applicant is not submitting an RFP, indicate the time period during which the
applicant expects to evaluate the bids received.

Line 11:

Provide the time period for which the Form 461 package should be posted on USAC’s
web site. Applicant can enter either the number of days (minimum 28 days) or specify an end
date for the posting (must be at least 28 days after USAC posts the applicant’s Form 461
package on the USAC website). USAC’s system will only allow the applicant to enter a date
that meets or exceeds the 28-day minimum requirement.

Line 12:

Requires the HCP to select the Category of Expense(s) being requested. The
applicant may select one or both categories. (Note that sites applying individually may not
receive support for one-time non-recurring charges of more than $5,000. This includes, for
5

example, reasonable and customary installation charges and equipment.) For more information
on expense categories, please visit http://www.usac.org/rhc/healthcare-connect/default.aspx">http://www.usac.org/rhc/healthcare-connect/default.aspx.

Line 12a:

To assist potential bidders in developing their responses to the Form 461, the
applicant is required to identify the potential applications and uses of the connection for which
support is sought. (

Note

: The Fund only provides support for costs associated with broadband
connectivity. The additional expenses associated with specific applications (e.g., exchange of
electronic health records) are not eligible for support under the Fund.) Select all that apply
under each of the following categories.
Interactive usage is an interaction that requires the service to have little to no delay.
Example: human-to-human interactions such voice and video conferencing.
Transactional usage is an interaction where minor delays are acceptable, but not above
1-2 seconds. Example: accessing a remote database to enter patient records and billing
information.
Bulk usage is an interaction usually done in the background with lower priority, or in off-
peak hours. Example: an automatic, after-hours process to create backup copies of
locally stored files at an off-site location.
Miscellaneous usage is only for capabilities that do not readily fit within the above three
categories. Example: requesting a backup or redundant connection.
For each capability selected, describe the anticipated usage level and usage period.
Usage Level should describe the anticipated level of usage for the selected capability.
Example: for video conferencing, the applicant may want to specify the usage level as “X
simultaneous video calls,” where X is the number of simultaneous video calls that the
connection must support.
Usage Period should describe when and/or how often the selected capability will be
used (e.g., 24x7x365, business hours, after hours, intermittent).

Line 12b-12c:

List the HCP number(s) for any off-site data center or off-site administrative for
which support is sought.

Lines 13:

Identify the primary point of contact for potential vendors. This contact should be
able to provide additional technical details or answer specific questions about the requested
services.
The contact may be (1) the HCP’s physical location contact (the contact listed in Block 2 of
Form 460); (2) the HCP’s Primary Account Holder (the contact listed in Block 4 of Form 460), or
(3) “Other.” If you choose one of the first two options, the contact information provided on Form
460 will be carried over to this line. If selecting “other,” provide the required contact information
in Line 13b.

C. Block 3: Consortium Request for Services

Only complete lines 14-19 if applying as a consortium.
6

Line 14:

List the HCP numbers for all sites that are part of this request for services. This
includes all eligible HCP sites and ineligible sites (including ineligible HCP sites, off-site data
centers, and off-site administrative offices).

Lines 15:

Indicate whether the consortium has prepared and is submitting an RFP with the
Form 461. See Additional Documentation in Block 6 below for information about when the
submission of an RFP is required.

Line 15a:

If the consortium is submitting an RFP with the form, indicate the reason(s) for
submitting an RFP. See instructions for Block 5 below for a list of the circumstances requiring
the use of an RFP.

Line 15b:

If the consortium is not submitting an RFP, indicate the expected dates of service.

Line 15c:

If the consortium is not submitting an RFP, indicate the time period during which the
applicant expects to evaluate the bids received.

Line 16:

Provide the time period for which the Form 461 package should be posted on USAC’s
web site. Applicant can enter either the number of days (minimum 28 days) or specify an end
date for the posting (must be at least 28 days after USAC posts the applicant’s Form 461
package on the USAC website). USAC’s system will only allow the applicant to enter a date
that meets or exceeds the 28-day minimum requirement.

Line 17:

Select the Category of Expense(s) requested. For more information on expense
categories, please visit http://www.usac.org/rhc/healthcare-connect/default.aspx">http://www.usac.org/rhc/healthcare-connect/default.aspx.

Line 17a:

If the consortium filing this Form is seeking bids for only “Infrastructure/Outside
Plant,” it is required to certify that it previously posted a Form 461 requesting the proposed
services to be provided over leased/tariffed facilities or services, and the prior Form 461
resulted in no bids. See paragraph 73 of the Healthcare Connect Fund Order. Provide the Form
461 Application Number for the prior posting here.

Line 18:

If an RFP is submitted, provide a brief summary of the RFP.
If an RFP is not being submitted, enter sufficient information in Line 18 regarding the desired
services to enable an effective competitive bidding process, including, at a minimum, a
summary of anticipated capabilities for the services being requested as well as usage level and
usage time for each such capability. (See line 12a and associated instructions above.)
Applicants that include a particular vendor’s name, brand, product or service in the description
must also use the words “or equivalent” in the description in order to avoid the appearance that
the applicant has pre-selected the named vendor or intends to give the vendor preference in the
bidding process.

Line 19:

Identify the primary point of contact that can provide additional technical details or
answer specific questions from potential vendors about the requested services. Indicate if it is
the Project Coordinator or Assistant Project Coordinator from Block 4 of the Form 460 or “other.”
If “other,” provide the required contact information in Line 19a.
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D. Block 4: Declaration of Assistance (to be completed by all applicants)

Line 20:

Select whether any consultants, service providers, or any other outside experts,
whether paid or unpaid, aided in the preparation of the Forms 460 or 461, RFP, bid evaluation,
or network plan. An outside expert is anyone who is not an employee of the Consortium
Leader, consortium member, or HCP (if applying individually). An employee of the Consortium
Leader, consortium member, or HCP (if applying individually) may be considered an “outside
expert” if he or she helped prepare the Form 460 or 461 outside of the scope of his or her
employment.

Line 21:

If the applicant, selected “yes” in line 20, list the contact information for all consultants,
service providers, and outside experts that assisted in preparing any part of the Forms 460, 461,
RFP, bid evaluation, or network plan. Include the person’s name, title, employer, address, and
organization type (such as consulting firm).

E. Block 5: Bid Evaluation (to be completed by all applicants)

Line 22:

List the selection criteria that will be used to demonstrate how the applicant will
choose the most “cost-effective” bid received as a result of this request for services. The
applicant must develop a scoring matrix, or a list of weighted evaluation criteria, that will be
used to evaluate bids. Price must be a primary factor, but need not be the only primary factor.
However, no single factor may receive a weight greater than price. Some examples of other
evaluation criteria include, but are not limited to, bandwidth, quality of transmission, reliability,
previous experience with the service provider, and technical support. The applicant must then
assign weights (with total weight equaling 100%) to the criteria and list both the weights and
criteria in Block 5. Any RFP used by the applicant must also include the list of weighted
evaluation criteria provided in Block 5.

F. Block 6: Additional Documentation (to be completed by all applicants)

Line 23:

Provide a list of all supporting documentation submitted with this Form 461.
Request for Proposal: Applicants must submit an RFP with its Form 461 if one or more of the
following apply:
 The consortium is seeking more than $100,000 in program support in a funding year.
 The applicant is required to issue an RFP under applicable state, Tribal, or local
procurement rules or regulations.
 The consortium is seeking support for infrastructure (i.e., HCP-owned facilities) as well
as services. Note that applicants seeking support for long-term capital investments,
such as HCP-constructed infrastructure or fiber IRUs, must also seek bids in the same
RFP from vendors who propose to meet those needs via services provided over vendor-
owned facilities for a time period comparable to the life of the proposed capital
investment.
 The applicant elects to use an RFP in the competitive bidding process.
http://www.usac.org/rhc/healthcare-connect/default.aspx">Example RFPs can be found at http://www.usac.org/rhc/healthcare-connect/default.aspx.
Network Plan: A consortium applicant must submit a narrative of its network plan that includes
the following information:
 Goals and objectives of the proposed network,
8

 Strategy for aggregating the specific needs of the HCPs (including providers that serve
rural areas) within a state or region,
 Strategy for leveraging existing technology to adopt the most efficient and cost-effective
means of connecting those providers,
 How the broadband services will be used to improve or provide health care delivery,
 Any previous experience in developing and managing health IT (including telemedicine)
programs, and
 A project management plan outlining the consortium’s leadership and management
structure and a work plan, schedule, and budget.
Consortium applicants are required to use program support for the purposes described in their
narrative. An applicant will have the opportunity to amend its narrative, if needed, when it
submits its request for funding commitment.
Letters of Agency: Consortium applications must include letters of agency (LOAs)
demonstrating that the Consortium Leader is authorized to submit the request for services
(Form 461) on behalf of each HCP listed in Line 14 of this Form 461. See 47 C.F.R. §
54.632(a)(1). If the Consortium Leader has previously submitted the required LOAs, indicate
the Form 460 application number for each HCP listed in Line 14.

G. Block 7: Certifications

Applicant is required to provide certifications in lines 24-37 in order to receive Healthcare
Connect Fund support. For individual HCP applicants, certifications must be signed by an
officer or director of the HCP or other authorized employee of the HCP. For consortium
applicants, an officer, director, or other authorized employee of the Consortium Leader must
sign the required certification. See 47 C.F.R. § 54.649.
A third-party (e.g., consultant) is prohibited from certifying, signing, or submitting the Form 462,
unless USAC receives, prior to the submission of the form, a written, dated, and signed
authorization from the relevant officer, director, or other authorized employee stating that the
individual HCP or Consortium Leader accepts all potential liability from any errors, omissions, or
misrepresentations on the forms and/or documents being submitted by the third party. If not
previously provided to USAC, submit any such required letter of authorization to USAC and
obtain USAC approval before signing and submitting this form.

Line 24:

Certifies that applicant’s representative is authorized to submit this form on behalf of
the consortium or HCP.

Line 25:

Certifies that the information provided in this form and in any attachments is true and
correct.

Line 26:

Certifies that applicant has followed applicable state, Tribal, or local procurement
rules.

Line 27:

Certifies that applicant will only use Healthcare Connect Fund support for purposes
reasonably related to the provision of healthcare service or instruction that the HCP is legally
authorized to provide under the law of the state in which the services are provided. In addition,
the applicant certifies that the supported connection(s) and network equipment will not be sold,
resold, or transferred in consideration for money or any other thing of value.
9

Line 28:

Certifies that the applicant satisfies all of the requirements under Section 254 of the
Act and applicable Commission rules.

Line 29:

Certifies that applicant has reviewed all program requirements and will comply with
those requirements.

Line 30:

Certifies that all documentation associated with the form will be retained for a period of
at least five years pursuant to 47 C.F.R. § 54.648. Documentation includes all bids, contracts,
scoring matrices, and other information associated with the competitive bidding process, and all
billing records for services received.

Lines 31-38:

Requires the signature, name, contact information, and employer’s FCC RN for
the person authorized to sign on behalf of the individual HCP or the Consortium Leader. The
name of the individual who submitted the form, contact information, and employer’s FCC RN
should be the same as the information submitted in Block 4 of the FCC Form 460.

IV. REMINDERS

 This Form 461 must be submitted and the competitive bidding process completed before
USAC may provide support for the requested services, network equipment, and/or
infrastructure.
 Incomplete forms or forms missing required documentation will not be processed. For
assistance in completing this form, contact USAC RHC at 1-800-453-1546 or rhc-
assist@usac.org.
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