FCC Form 460 Description of Eligibility and Registration

OMB 3060-0804

X/XX/2020

Rural Health Care

Healthcare Connect Fund Program

Description of Eligibility and Registration (FCC Form 460)

Note: This is a representative description of the information to be collected via the online portal and is not intended to be a visual representation of what each applicant will see, the order in which they will see information, or the exact wording or directions used to collect the information. Where possible, information already provided by applicants from previous filing years or that was pre-filed in the system portal will be carried forward and auto-populated into the form.

Item #	Field Description	Purpose/Instructions
1	Applicant’s FCC Form Nickname	To create a unique identifier for this request, the user simply enters a nickname (e.g., 2016 Funding Year Homewood FCC Form 460).
2	FCC Form 460 Application Number	Auto-generated by the system: This is a unique USAC-assigned identifier for this request that is automatically created when a user creates an FCC Form 460.
3	Site Name	This is the name of the organization submitting this request.
4	Legal Entity Name	This is the name of the Legal Entity that owns and/or operates the site. In some cases, the Legal Entity Name may be different from the Entity or Consortium Name.
5	Legal Entity FCC Registration Number	This is the unique FCC identifier for the Legal Entity that owns and/or operates the site.
6	Employer Identification Number (EIN)	The EIN, also known as a Federal Tax Identification Number, is used to identify a business or non-profit entity.
7	Site Number	Auto-generated by the system: This is the unique identifier assigned by the Universal Service Administrative Company (USAC) to the organization identified in the Site Name. This number is automatically created when a user creates an FCC Form 460.
8	National Provider Identifier (NPI)	This is the ten-digit health care facility NPI used on Medicare and Medicaid claims.
9	Organization Taxonomy Code	This is the ten-digit Health Care Provider Taxonomy Code that corresponds to the NPI.
10	Site Taxonomy Code	Optional. Should the Organization Taxonomy Code not adequately describe the site, the user may add additional Taxonomy Codes.
11	Site Address	This is the site’s physical address, county, city, state, zip code and geolocation. Geolocation only applies to a site that does not have a street address.
12	Site Website	Optional. The website address of the site.
13	Type of Registration	This is the selection of the applicant as a health care provider (HCP) site, Consortium, Off-site data center, Off-site administrative office or Ineligible site.
14	Type of Registration: If Data Center	A list of all sites (eligible and ineligible) that will use the services of the data center.
15	Type of Registration: If Administrative Center	A list of all sites (eligible and ineligible) that will use the services of the administrative center.
16	Eligibility Entity Type that Seeks Support	These are the eligible health care provider categories as provided in 47 CFR § 54.600(b): community health center or health center providing health care to migrants; community mental health center; local health department or agency; non-profit hospital; post-secondary educational institution offering health care instruction, including a teaching hospital or medical school; rural health clinic; skilled nursing facility; and consortium of the above entities. In addition, a dedicated emergency room (ER) of a rural, for-profit hospital and part-time eligible entity located in an ineligible facility are eligible for support under the RHC Program. Only an entity that is either a public or non-profit health care provider is eligible for support. 47 CFR § 54.601(a)(1). Each separate site or location of a health care provider shall be considered an individual health care provider for purposes of calculating support. 47 CFR § 54.601 (a)(2).
17	Eligibility Entity Type that Seeks Support: If Rural Health Clinic	If the user chooses “Rural Health Clinic,” the user selects whether or not the site is a mobile rural HCP.
18	Eligibility Entity Type that Seeks Support: If Non-Profit Hospital	If the user chooses “Non-Profit Hospital,” then the user indicates if the hospital is a Critical Access Hospital.
19	Eligibility Entity Type that Seeks Support: If Non-Profit Hospital	If the user chooses “Non-Profit Hospital,” then the user will be asked to provide how many licensed patient beds are on site.
20	Eligibility Entity Type that Seeks Support: If Community Mental Health Center	If the user chooses “Community Mental Health Center,” then the user must submit the Community Mental Health Center Checklist and a copy of the HCP’s operating license.
21	Eligibility Entity Type that Seeks Support: Additional Site Information	If applicable, the user indicates if the site is located on Tribal lands, operated by the Indian Health Service, and/or otherwise affiliated with a Tribal entity.
22	Eligibility Entity Type that Seeks Support: Additional Site Information	Optional. The user may provide a brief explanation of why the site qualifies as the eligibility category selected.
23	Consortium Name	The name of the consortium.
24	Consortium Number	The unique identifier assigned by USAC to the consortium listed in Consortium Name.
25	Consortium: Legal Entity Identification	The user indicates if the consortium is a Legal Entity.
26	Consortium FCC Registration Number	This is the unique FCC identifier for the consortium.
27	Consortium Leader Name	This is the organization that will serve as the main point of contact for USAC and the FCC, and who will act on behalf of the consortium members.
28	Consortium Leader Type	The user identifies the consortium as either: an eligible Health Care Provider member of the consortium, State organization, Public sector (government) entity, Non-Profit entity, or Consortium itself if organized as a Legal Entity. A state organization, public sector entity, or non-profit entity may obtain an exemption to allow the organization to perform service provider functions and provide application assistance.
29	Consortium Leader: If Eligible Health Care Provider Member	If the user selects “Eligible health care provider member of the consortium,” then they must provide a site number for their site.
30	Written Agreement Allocating Legal and Financial Responsibility	The user indicates if the consortium has a written agreement allocating legal and financial responsibility. By default, the consortium leader is the legally and financially responsible entity for the conduct of activities supported by the universal service fund.
31	Written Agreement Allocating Legal and Financial Responsibility: Yes	User uploads “Written Agreement Allocating Legal and Financial Responsibility” document.
32	Exemption for State Organization, Public Sector Entity, or Non-Profit Entity Serving as Both Service Provider and Consortium Leader/Consultant	For consortia only. An entity seeking to obtain an exemption to be able to serve as both the service provider and the consortium leader/consultant, must make a showing to USAC that they have set up an organizational and functional separation between the consortium leader/consultant and service provider roles and responsibilities. This exemption must be obtained before preparing the FCC Form 461 and associated documents.
33	Exemption for State Organization, Public Sector Entity, or Non-Profit Entity Serving as Both Service Provider and Consortium Leader/Consultant: Yes	User provides written documentation showing that they have established and implemented an organizational and functional separation between the consortium leader and service provider roles and responsibilities.
34	Consortium Leader Address	This is the consortium leader mailing address, county, city, state, and zip code.
35	Consortium Website	Optional. The website address of the consortium.
36	Primary Account Holder Contact Name	This is the name of the person who should be contacted with questions about this request. The Consortium Leader or Entity must designate a Primary Contact for purposes of interacting with the Commission and USAC. This person must be employed by the Legal Entity listed on this FCC Form. The Primary Contact is authorized to view, create, and enter data in the forms, and electronically certify, sign and submit forms, on behalf of the Entity or Consortium.
37	Primary Contact Employer	This will auto-populate with the information listed within “Legal Entity Name” (Item # 4).
38	Primary Contact Mailing Address	This is the mailing address, county, city, state, and zip code of the person who should be contacted with questions about this request.
39	Primary Contact Telephone Number	This is telephone number of the person who should be contacted with questions about this request.
40	Primary Contact Email Address	This is the email address of the person who should be contacted with questions about this request.
41	Legal Entity Website	Optional. The website address of the Legal Entity that owns and/or operates the Entity or Consortium. Explains more about what the Legal Entity is in relation to a site and consortium. This is the website for the organization listed in Item #4.
42	Additional Contact(s)	Optional. Allows the user to add additional contact person(s) to the request. Additional contacts will have access to forms and be authorized to answer specific questions about the applications associated with a funding request. They also be authorized to sign, certify and submit forms on behalf of the applicant. To add an additional contact person, the user must provide the contact’s name, employer, mailing address, county, city, state, zip code, telephone number, email address and website.
43	Supporting Documentation	Optional. Provides an option for the user to upload and submit documents to support their request.
44	I certify under penalty of perjury that I am authorized to submit this request on behalf of the site or consortium.	Applicants are required to provide this certification in order to receive Healthcare Connect Fund Program support. For individual Health Care Provider applicants, certifications must be signed by an officer or director of the Health Care Provider or other authorized employee of the Health Care Provider. For consortia applicants, an officer, director, or other authorized employee of the Consortium Leader must sign the required certification. The Authorized Person is required to provide all required certifications and signatures.
45	I certify under penalty of perjury that I have examined this request and attachments and to the best of my knowledge, information, and belief, all information contained in this request, and in any attachments, is true and correct.	See Item #44, Purpose/Instructions above.
46	I understand that all documentation associated with this request or demonstrating compliance with the rules must be retained for a period of at least five years after the last day of service delivered in a particular funding year pursuant to 47 CFR § 54.631, or as otherwise prescribed by the Commission’s rules.	See Item #44, Purpose/Instructions above *Does not apply to COVID-19 Telehealth Program
47	If applying as an individual Health Care Provider site, I certify under penalty of perjury that the Health Care Provider is either a non-profit, public entity or a dedicated ER of a rural for-profit hospital.	See Item #44, Purpose/Instructions above. Only applies to those applying as an individual Health Care Provider site.
48	If applying as an individual Health Care Provider site, I certify under penalty of perjury that the site is located in a designated rural area, or was previously grandfathered as rural.	See Item #44, Purpose/Instructions above. Only applies to those applying as an individual Health Care Provider site. *Does not apply to Pilot Program or COVID-19 Telehealth Program.
49	If applying as a consortium, I certify under penalty of perjury that the eligible Health Care Providers participating in the consortium are either non-profit or public entities or dedicated ER(s) of a rural for-profit hospital.	See Item #44, Purpose/Instructions above. Only applies to those applying as a consortium.
50	If applying as a consortium, I understand I must obtain letters of agency (LOAs) from each consortium member that grants me the authority to complete, sign, and submit all requests for the funding year(s) for which support is sought.	See Item #44, Purpose/Instructions above. Only applies to those applying as a consortium.
51	Signature	The Authorized Person is required to provide all required certifications and signatures. The request must be certified electronically.
52	Date Submitted	Auto generated by system: This date is assigned based on the date the user submits the FCC Form 460.
53	Date Signed	Auto generated by system: This date is assigned based on the date the user certifies the FCC Form 460.
54	Authorized Person	This is the name of the Authorized Person (either the Primary Contact or an Additional Contact) that is certifying the FCC Form. This field will be auto-populated if the name of the Authorized Person is already within the system.
55	Authorized Person’s Employer	Auto-generated by the system: Based on either previous information entered in this FCC Form 460 or based on the details of the logged in user. This is the name of the employer of the Authorized Person certifying the FCC Form. This field will be auto-populated if already within the system.
56	Authorized Person’s Employer FCC Registration Number	Auto-generated by the system: Based on either previous information entered in this FCC Form 460 or based on the details of the logged in user. This is the FCC Registration Number of the Authorized Person signing the FCC Form. This number may be the FCC RN of the Legal Entity, Consortium or Site. This field will be auto-populated if already within the system.
57	Authorized Person’s Title/Position	Auto-generated by the system: Based on either previous information entered in this FCC Form 460 or based on the details of the logged in user. This is the title or position of the Authorized Person certifying the FCC Form. This field will be auto-populated if already within the system.
58	Authorized Person’s Mailing Address	Auto-generated by the system: Based on either previous information entered in this FCC Form 460 or based on the details of the logged in user. This is the address (can be physical address or mailing address) of the Authorized Person certifying the FCC Form. This field will be auto-populated if already within the system.
59	Authorized Person Telephone Number	Auto-generated by the system: Based on either previous information entered in this FCC Form 460 or based on the details of the logged in user. This is the telephone number of the Authorized Person certifying the FCC Form. This field will be auto-populated if already within the system.
60	Authorized Person Email Address	Auto-generated by the system: Based on either previous information entered in this FCC Form 460 or based on the details of the logged in user. This is the email address of the Authorized Person certifying the FCC Form. This field will be auto-populated if already within the system.
61	Third Party Authorization (TPA)	If applicable, the user must provide a TPA providing written authorization to a third party/consultant to complete and submit the FCC Form on behalf of the Health Care Provider or consortium.
62	Letter of Agency (LOA)	For Consortia only. If applicable, the user must provide LOAs providing written authorization to the Primary or Additional Contact(s) of a consortium to act on behalf of each participating Health Care Provider or health system not owned or operated by the consortium or organization operating the consortium.
63	Letter of Exemption (LOE)	For Consortia only. If applicable, the user must provide LOEs providing written authorization to the Primary or Additional Contact(s) of a consortium to submit requests for sites owned and operated by the consortium.

FCC NOTICE FOR INDIVIDUALS REQUIRED BY THE PRIVACY ACT AND THE PAPERWORK REDUCTION ACT

Part 54 of the Federal Communications Commission’s (FCC) rules authorize the FCC to collect the information in this form. Responses to the questions herein are required to obtain the benefits sought by this form. Failure to provide all requested information will delay the processing of the form or result in the form being returned without action. Information requested by this form will be available for public inspection. The information provided will be used to determine whether approving the request is in the public interest.

We have estimated that your response to this collection of information will take 1 hour.  Our estimate includes the time to read the instructions, look through existing records, gather and maintain the required data, and actually complete and review the form or response.  If you have any comments on this estimate, or on how we can improve the collection and reduce the burden it causes you, please write the Federal Communications Commission, Office of Managing Director, AMD‑PERM, Paperwork Reduction Act Project (3060‑0804), Washington, DC 20554.  We will also accept your comments via the Internet if you send them to PRA@fcc.gov.  Please DO NOT SEND COMPLETED FORMS 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 we fail to provide you with this notice.  This collection has been assigned an OMB control number of 3060‑0804.

THIS NOTICE IS REQUIRED BY THE PAPERWORK REDUCTION ACT OF 1995, P.L. 104-13, OCTOBER 1, 1995, 44 U.S.C. SECTION 3507.

6