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FCC Form 460

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Released: August 5, 2014
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FCC Form 460

OMB Approved 3060-0804

Estimated Time Per Response: 1 hour

Rural Health Care (RHC) Universal Service

Eligibility and Registration Form

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

Block 1: General Information

1 Date Submitted:

Determine eligibility of an HCP site

2 Applying to:

Determine eligibility of Consortium

Register an ineligible site

Register an off-site data center

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.

Block 2: Site Information – Physical Site

Enter the actual physical location of the site.

3 HCP Number

4 Site Name

5 Name of Legal Entity

6 Enter FCC Registration Number (FCC RN) for Line 5 legal entity:

6a If the Line 5 legal entity does not have an FCC RN and only plans to participate as a consortium member, applicant

may enter FCC RN for the Consortium (see instructions for more detail):

7 Site Contact Name

8 Address Line 1

9 Address Line 2

10 County

11 Geo Location (if no street address)

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

Ineligible State organization

An eligible HCP participating in the Consortium

Ineligible public sector (government) entity

HCP Number: ________________________

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

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Block 2: Site Information – Physical Site

34 Secondary Account Holder (Application Contact/Assistant Project Coordinator)

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

Block 5: Eligibility Category

43 Select the category that describes the HCP site

(If seeking an eligibility determination for a Consortium, “Consortium of the above” will be automatically selected)

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:

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.

I declare under penalty of perjury that I have examined this form and attachments and to the best of my

54

knowledge, information, and belief, all information contained in this form and in any attachments is true and

correct.

If applying as an individual health care provider site, I certify that the health care provider is a non-profit or

55

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.

If applying as a consortium, I understand I must obtain letters of agency from each consortium member that

58

grants me the authority to complete, sign, and submit all forms for the funding year(s) for which support is

sought.

FCC Form 460

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Block 7: Certifications and Signatures

59 Signature

60 Date

61 Printed Name of Authorized Person

62 Title/Position of Authorized Person

63 Phone

Ext.

64 Email

65 Employer

66 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

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.

FCC Form 460

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, Word Document, or as plain text.

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