State, Local or Tribal Governments

[insert date of Letter of Authorization]

Office of the Secretary
Federal Communications Commission
445 12th Street, S.W.
Washington, D.C. 20554
Funding Commitment Date: [insert date]
Funding Commitment Number: [insert number located on funding commitment notification]
Health Care Provider Name: [insert name]
Health Care Provider Number: [insert your HCP no. provided by USAC]
Subject: Letter of Authorization
FCC Staff,
[insert entity name that submitted application and received the funding commitment] applied for
funding under the COVID-19 Telehealth Program and received a funding commitment on our
behalf as the consortium lead. We therefore authorize [insert entity name that submitted
application and received the funding commitment] to accept disbursements of funding under the
COVID-19 Telehealth Program on our behalf. We understand that any funding received by
[insert entity name that submitted application and received the funding commitment] shall be
provided to our health care provider site to reimburse us for the respective costs incurred under
the COVID-19 Telehealth Program. We also understand and certify under penalty of perjury
that this funding shall only be used by eligible health care providers to obtain the
telecommunications services, information services, and connected devices to provide telehealth
services in response to the coronavirus 2019 disease (COVID-19) pandemic.
Should you have any questions or need further information, please contact me at your
convenience.

Sincerely,

[signature]
______________________________________________
[insert printed name of Authorized Person to sign on behalf of the HCP]
[insert title of Authorized Person]

__________
Date