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DA-13-590A6

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New FCC Form 462
Subject to Approval by OMB 3060-0804
Estimated time per response: 2 hours

Rural Health Care (RHC) Universal Service

Healthcare Connect Fund


Funding Request Form


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

Block 1: General Information

1 Funding Year ___________
2 Funding Request Number (FRN):
3 HCP Number:
4 Site Name/Consortium Name:

Block 2: Competitive Bidding Information

5 FCC Form 461 Application Number:
6 Allowable Contract Selection Date (ACSD):
7 Number of vendors who bid:
8 Request for competitive bidding exemption (Only complete if claiming a competitive bidding exemption).
Annual Undiscounted Cost of $10,000 or less
Government Master Services Agreement
Contract ID:
Friendly Name:
Pre-Approved Master Services Agreement
Contract ID:
Friendly Name:
Evergreen Contract
Contract ID:
Friendly Name:
E-Rate Approved Contract
Contract ID:
Friendly Name:

Block 3: Vendor Information

9 Service provider identification number (SPIN):
10 Vendor name:

Block 4: Type of Funding Request

11 Individual HCP, single eligible expense
Individual HCP, multiple eligible expenses
Consortium
15 Circuit ID (optional)

DRAFT

Application

Block 5: Single Eligible Expense Request for Funding

12 Category of Expense
13 Expense Type
14 Bandwidth
14a Is this service symmetrical? Yes No
If no, what is the upload bandwidth ___________.
What is the download bandwidth ___________.
16 Percentage of expense eligible
17 Does the Service Type include both eligible and ineligible components? Yes No
If yes, percentage of usage eligible ___________________
18 Billing Account Number (BAN)
19 Contract ID
19a Date contract signed
19b Expected service start date
19c Length of initial contract term
19d Number of contract extensions
19e Length of optional extension(s) combined
20 Circuit start location
21 Circuit end location
22 Is this a multi-year funding request? Yes No
Multi-year commitments cannot exceed 3 funding years and may not
extend beyond the expiration date of an Evergreen Contract.
23 Expense frequency
24 Quantity of expense periods
25 Undiscounted cost per expense period
26 Source of HCP contribution
27 One-time installation charges
FCC Form 462

Block 1: General Information

28 This contract contains a Service Level Agreement. Yes No
If yes, provide the following information a. Latency:
b. Jitter:
concerning the SLA in the contract:
d. Packet Loss:
d. Reliability:

Block 6: Multiple Eligible Expenses and Consortium Requests for Funding (attach Network Cost Worksheet)

29 Total undiscounted cost for eligible recurring expenses
30 Total undiscounted cost for eligible non-recurring expenses

Block 7: Additional Documentation

31 List all supporting documentation (Competitive bids, Contract, etc.) that is required to be submitted with this form.
Type of Documentation
a.
b.
c.

Block 8: Request for Confidentiality

32 Is applicant requesting confidential treatment and non-disclosure of commercial and financial information? (See
instructions for specific information covered by this request.) Yes No

Block 9: Certifications

33
I certify that I am authorized to submit this request on behalf of the health care provider or consortium.
I declare under penalty of perjury that I have examined this form and attachments and to the best of my
34
knowledge, information, and belief, all information contained in this form and in any attachments is true and
correct.
I certify under penalty of perjury that the health care provider or consortium has considered all bids
received and selected the most cost-effective method of providing the requested services. The “most cost-
35
effective service” 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.” 47 C.F.R. Sec. 54.642(c).
36
I certify under penalty of perjury that all Healthcare Connect Fund support will be used only for the eligible
program purposes for which support is intended.
37
T

DRAFT

I certify that the health care provider or consortium is not requesting support for the same service from both
the Telecommunications Program and the Healthcare Connect Fund.
I certify that the health care provider or consortium satisfies all of the requirements under Section 254 of the
38
elecommunications Act of 1996, as amended, and applicable Commission rules, and understand that any
letter from the Administrator that erroneously commits funds for the benefit of the applicant may be subject to
recission.
39
I certify that I have reviewed all applicable requirements for the program and will comply with those
requirements.
I understand that all documentation associated with this application, including all bids, contracts, scoring
40
matrices, and other information associated with the competitive bidding process, and all billing records for
services received, 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.
41 Signature
42 Date
43 Printed Name of Authorized Person
44 Title/Position of Authorized Person
45 Phone
Ext.
46 Email
47 Employer
48 Employer’s FCC RN
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
FCC Form 462

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 2 hours 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.

DRAFT

FCC Form 462

Rural Health Care (RHC) Universal Service
Healthcare Connect Fund
Network Cost Worksheet (attach, if required, to Form 462)
Quality of Service
Guarantees (if
Site
applicable and
Information
Contract Information
Eligible Expense Information
available)
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DRAFT

Rural Health Care (RHC) Universal Service
Healthcare Connect Fund
Network Cost Worksheet (attach, if required, to Form 462)
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DRAFT

Document Outline

  • FCC Form 462.pdf
  • Network Cost Worksheet.pdf

Note: We are currently transitioning our documents into web compatible formats for easier reading. We have done our best to supply this content to you in a presentable form, but there may be some formatting issues while we improve the technology. The original version of the document is available as a PDF, , or as plain text.

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