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Commission Document Attachment

DA-13-590A9

Subject to Approval by OMB
3060-0804
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FCC Form 463 Instructions

Rural Health Care Universal Service
Healthcare Connect Fund
Invoice and Request for Disbursement 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................................................................................................................... 3
D. Next Steps....................................................................................................................... 3
E. For More Information....................................................................................................... 3
III.
SPECIFIC INSTRUCTIONS FOR FILING FORM 463 ..................................................... 3
A. Block 1: General Information ........................................................................................... 3
B. Block 2: Eligible Expenses............................................................................................... 4
C. Block 3: Dates, Quantities, and Costs ............................................................................. 5
D. Block 4: Calculation of Support Amount.......................................................................... 5
E. Block 5: Supporting Documentation................................................................................ 6
F.
Block 6: Vendor Certifications and Signatures................................................................ 6
G.
Block 7: Applicant Certifications and Signatures: ........................................................ 6
IV.
REMINDERS................................................................................................................... 7
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I. PURPOSE OF FORM

The Federal Communications Commission (FCC) Form 463 is the invoice that serves as the
request to Universal Service Administrative Company (USAC) for the disbursement of funding
from the Healthcare Connect Fund (Fund) for the services, equipment, and/or facilities set forth
in an applicant’s funding commitment letter. The filing of the Form 463 is a joint process
between the applicant and the vendor (service provider). The applicant initiates the filing of the
Form 463, but the vendor has the opportunity to review and revise the Form 463 before it is
submitted to USAC for processing and payment. Prior to submission of Form 463, the
consortium (or, HCP, if participating individually) must certify that the form is accurate and that
the consortium or HCP has paid its required 35 percent contribution. The vendor must also
certify to the accuracy of the form.
If the applicant requested confidential treatment and non-disclosure of commercial and financial
information in Line 32 of the associated FCC Form 462, that request will cover the information
provided in Line 9 (Total Invoice Amount), Column L (Total Cost Invoiced (Undiscounted),
Column O (Total Eligible Actual Cost (Undiscounted)), and Column P (USF Support Amount to
be Paid) of this Form 463.
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

A. Who Must File

Filing the Form 463 requires the participation of both the vendor (service provider) and the
applicant. To start the filing process, the applicant must first complete the Form 463. The
applicant must also certify to the form’s accuracy and that it has paid its 35 percent required
contribution to the vendor. After the applicant has completed the form and made the required
certifications, it must electronically submit the form to USAC.
Upon receipt of the completed Form 463 from the applicant, USAC will electronically notify the
vendor that the invoice is ready for review. The vendor must then review and certify to the
form’s accuracy and that it has credited the applicant’s account with the amounts listed in
Column U (USF Support Amount to be Paid) on the Form 463 (the portion of total costs to be
supported by the Healthcare Connect Fund for each line item). After the vendor has made its
certifications, it should electronically re-submit the form to USAC. If the vendor makes any
revisions to the Form 463 (including the attachment of any supporting documentation), the
applicant must review and re-certify the form before USAC will begin processing it. See Where
to File
below for more details.
2

B. When to File

The applicant and vendor should seek to submit a completed Form 463 as soon as possible.
The Form 463 may only be submitted after:
 The applicant receives a funding commitment,
 The vendor has installed/started/commenced the requested services, network
equipment, and/or facilities, as applicable, and
 The applicant has received a bill from the vendor.
The applicant and vendor must file all necessary Form 463(s) within six months after the end
date of the funding commitment, as specified on the funding commitment letter issued by USAC.
The deadline normally will be six months after the end of the funding year unless the funding
commitment is multi-year.

C. Where to File

Applicants and vendors are required to submit the Form 463 electronically through USAC’s
Rural Health Care (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
http://www.usac.org/rhc/healthcare-connect/default.aspx">are also 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

Once the Form 463 has been reviewed and approved, the vendor will receive payment either
directly or as an offset to its universal service contribution obligation, depending on which option
the vendor selected on its FCC Form 498.

E. For More Information

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

III. SPECIFIC INSTRUCTIONS FOR FILING FORM 463

A. Block 1: General Information

Line 1

: The RHC Invoice Number uniquely identifies each Form 463. USAC will generate this
number.

Line 2

: Enter the Funding Request Number (FRN) for which this Form 463 is seeking payment.
The FRN is provided in the funding commitment letter. Each funding commitment letter has a
unique FRN.
The remaining lines in Block 1, except for line 6 (Vendor or Applicant Invoice Number) and line
9 (Total Invoice Amount), will be automatically populated based on the FRN selected. If any of
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the automatically populated fields in Block 1 are incorrect, contact RHC (1-800-453-1546, rhc-
assist@usac.org) to receive additional information on how to proceed.

Line 3

: The HCP Number associated with the FRN.

Line 4

: The Consortium or HCP Name associated with the above HCP Number.

Line 5

: The Funding Year(s) associated with the FRN entered above.

Line 6 (Optional)

: Enter the Vendor or Applicant Invoice Number, if desired. This field enables
the vendor and/or applicant to include an identifier to more easily track the Form 463 within the
billing system of the vendor or applicant.

Line 7

: The Service Provider Identification Number (SPIN) associated with the FRN entered
above. The SPIN will be included in the funding commitment letter.

Line 8

: The Vendor Name associated with the above SPIN. The Vendor Name will be included
in the funding commitment letter.

Line 9

: The Total Invoice Amount is the total amount that USAC will pay the vendor for services
listed on this invoice. The total invoice amount is the sum of the values in Column P (USF
Support Amount to be Paid). This value will be automatically calculated based on the values
entered below in Columns I-L.

B. Block 2: Eligible Expenses

Column A – FRN ID

: The Funding Request ID (FRN ID) is a separate and unique identifier
associated with each line item for which the applicant is seeking support. The FRN ID for each
line item is found in the funding commitment letter. Select the FRN ID(s) which will be
submitted to USAC for disbursement on this invoice.
Note: An applicant must file a separate Form 463 for each separate funding commitment letter
(FRN). Moreover, an applicant may not enter FRN ID(s) that are not associated with the FRN
entered in Block 1.
The remaining columns in Block 2 will be automatically populated based on the FRN and FRN
ID(s) selected. If any of the remaining fields in Block 2 are incorrect, contact RHC (1-800-453-
1546, rhc-assist@usac.org) to receive additional information on how to proceed.

Column B – Billing Account Number (BAN)

: If provided on the Form 462, this field will be
automatically populated. If it was not provided on the Form 462, the applicant will enter the
BAN associated with the FRN ID upon the submission of the first invoice for that FRN ID. On
subsequent invoices, the BAN will be pre-populated based on prior submission. The applicant
typically can find the BAN on the vendor’s bill. Contact the vendor with any questions regarding
the appropriate BAN to enter in this field.

Column C – HCP Number

: The HCP number of the site for which this line item is being
submitted.
4

Column D – Site Name

: The name of the site for which this line item is being submitted. The
name must match the name on record for the HCP Number listed for this line item.

Column E – Category of Expense

: The Category of Expense associated with the FRN ID.

Column F – Expense Type

: The Expense Type associated with the FRN ID.

Column G – Bandwidth

: The bandwidth, if applicable, for the line item.

C. Block 3: Dates, Quantities, and Costs

Column H – Service Start Date/Shipping Date or Last Day of Work

: Enter the actual date the
broadband service was started, the network equipment was shipped to the customer, or the last
day of work was completed, as applicable.

Column I – Billing Period Start Date

: Enter the first date of the billing period for this invoice, if
applicable. If the eligible expense is for a non-recurring expense, enter “N/A.”

Column J – Billing Period End Date

: Enter the last date of the billing period for this invoice, if
applicable. If the eligible expense is for a non-recurring expense, enter “N/A.”

Column K – Quantity of Items Invoiced

: Enter the quantity of items billed on this invoice. For
example, if applicant is invoicing for two routers, enter “2”. If applicant is invoicing for a single
connection (e.g., circuit), enter “1”.

Column L – Total Actual Cost Invoiced (Undiscounted)

: Enter the actual total undiscounted
cost for the applicable billing period being submitted for disbursement on this invoice. For
example, if the applicant is invoicing for a single month of recurring service, enter the total
actual cost
for the service, including any applicable taxes or surcharges. If the applicant has
received multiple bills from its vendor for the applicable service that it is submitting for
disbursement on a single invoice, calculate the total actual cost, including any applicable taxes
and surcharges, for the applicable line item on each bill and add together to determine the
total actual cost for the billing period.

D. Block 4: Calculation of Support Amount

Column M – Percentage of Expense Eligible

: The percentage of expense eligible for support
associated with the FRN ID. This is automatically populated based on the FRN ID selected.

Column N – Percentage of Usage Eligible

: The percentage of usage eligible for support
associated with the FRN ID. This is automatically populated based on the FRN ID selected.
If the percentage in Column M or N is incorrect, contact RHC (1-800-453-1546, rhc-
assist@usac.org) to receive additional information on how to proceed.

Column O – Total Eligible Actual Cost (Undiscounted)

: The total amount of the expense
that is eligible for USF support on this Form 463. The total eligible actual cost is automatically
5

calculated by multiplying Column L (Total Actual Cost Invoiced (Undiscounted)) by Column M
(Percentage of Expense Eligible) and by Column N (Percentage of Usage Eligible).

Column P – USF Support Amount to be Paid

: The total amount that USAC will pay the
vendor for this line item. The “USF Support Amount to be Paid” is capped at the support
amount specified in the funding commitment letter (FCL). First, USAC will multiply Column O
(Total Eligible Actual Cost (Undiscounted)) by the Fund discount percentage, as specified on
the funding commitment letter. The discount percentage is normally 65 percent, but may be
decreased if one or more of the funding caps are reached. See 47 C.F.R. § 54.675.
Second, USAC will pay the lesser of the calculated value and the support amount for the billing
period specified in the FCL. If the calculated value exceeds the funds available for the FRN ID,
the applicant may be able to pursue a reallocation of funds within the FRN. Contact RHC (1-
800-453-1546, rhc-assist@usac.org) to receive additional information on how to proceed.

E. Block 5: Supporting Documentation

Line 10

: Applicants and/or vendors may attach supporting documentation, including, but not
limited to, a copy of the bill(s) for the line item(s) being submitted on this Form 463. By
providing copies of the bills and/or other supporting documentations, the applicant and vendor
will ensure such documentation is available for any future audit. See 47 C.F.R. § 54.648.

F. Block 6: Vendor Certifications and Signatures

Lines 11-13:

The vendor representative must certify that: (1) he or she is authorized to submit
the Form 463 on behalf of the vendor, (2) the vendor has credited health care provider(s) and
FRN/FRN IDs listed on the invoice with the amount shown under Column U (USF Support
Amount to be Paid), (3) the dates, quantities, and costs provided under Block 3 of this Form 463
are true and correct.

Lines 14-21:

Require the signature, name, title, contact information, and employer’s FCC RN
for the person authorized to sign on behalf of the vendor.

G. Block 7: Applicant Certifications and Signatures:

Lines 22-25:

The representative of the Consortium Leader (or, HCP, if participating
individually) must certify that: (1) he or she is authorized to submit the Form 463 on behalf of the
health care provider or consortium, (2) the information provided on the Form 463 is true and
correct, (3) the HCP or consortium members have received the related services, network
equipment, and/or facilities itemized on the Form 463, and (4) the required 35 percent minimum
applicant contribution for each item on the Form 463 was funded by eligible sources as defined
in the FCC rules and that the required contribution has been remitted to the vendor.

Lines 26-33

: Require the signature, name, title, contact information, and employer’s FCC
Registration Number (FCC RN) for the person authorized to sign on behalf of the individual HCP
or the Consortium Leader. This should generally be the same information submitted in Block 4
of the FCC Form 460. For an individual HCP, an officer or director of the HCP or other
6

authorized employee of the HCP must sign the required certifications (a letter of authorization
(LOA) must be on record, if not an employee of the HCP). For a consortium, an officer, director
or other authorized employee of the Consortium Leader must sign the required certifications (an
LOA must be on record, if not an employee of the Consortium Leader).

IV. REMINDERS

 The applicant and vendor must complete the required Form 463(s) within six months
after the end of the funding commitment. The exact deadline is specified on the funding
commitment letter.
 USAC will not accept incomplete forms. For assistance in completing this form, contact
USAC RHC at 1-800-453-1546 or rhc-assist@usac.org.
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Document Outline


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