DR AF T New FCC Form 461 Rural Health Care (RHC) Universal Service Healthcare Connect Fund Request for Services Form Subject to Approval by OMB 3060-0804 Estimated time per response: 1 hour Read instructions thoroughly before completing this form. Failure to comply may cause delayed or denied funding. Block 1: General Information 1 Funding Year 2 HCP Number 3 Site Name/Consortium Name 4 Address Line 1 5 Address Line 2 6 County 7 City 8 State 9 Zip Code Block 2: Individual HCP Site Request for Services 10 Applicant has prepared and is submitting an RFP with this form. Applicant has not and will not prepare an RFP. 10a Expected dates of service 10b Expected bid evaluation period 11 Number of Days Posted Number of days USAC should post: ______________ Posting end date: ______________ 12 Category of Expense Requested (check all applicable): Network Equipment Leased/Tariffed Facilities or Services 12a Identify Anticipated Application(s) and Use(s) of the Supported Connection The Fund only provides support for costs associated with broadband connectivity. The additional expenses associated with specific applications (e.g., exchange of electronic health records) are not eligible for support under the Healthcare Connect Fund. (Select all that apply. Describe usage level and usage period for all selected.) Capability Usage Level Usage Period Category: Interactive Distance learning/training Real-time remote examination, consultation, and/or monitoring Video conferencing Voice service Other (describe): _____________ Category: Transactional Distance learning/training Electronic patient billing Exchange of electronic health records Internet access USAC Internal Use Only FCC Form 461 Application Number: FCC Form 460 Number: Posting Start Date: Posting End Date: Allowable Contract Selection Date (ACSD): Form 461 Friendly Name: DR AF T 15b Expected dates of service 15c Expected bid evaluation period 16 Number of Days Posted: Number of days USAC should post: ______________ Posting end date: ______________ 17 Category of Expense Requested: Network Design Network Equipment Infrastructure/Outside Plant Leased/Tariffed Facilities or Services Network Management/Maintenance/Operations Cost (not captured elsewhere) 17a If requesting only Infrastructure/Outside Plant, enter FCC Form 461 Application Number in which the Consortium previously requested Leased/Tariffed Facilities or Services. FCC Form 461 Application Number: I certify that the prior FCC Form 461 resulted in no responsive bids. FCC Form 461 Block 3: Consortium Request for Services 14 Participating Entities (list all sites, eligible and ineligible, participating in this request for services): HCP Number: HCP Number: HCP Number: HCP Number: 15 Applicant has prepared and is submitting an RFP with this form. If selected, complete 15a. Applicant has not and will not prepare an RFP. 15a Applicant is submitting an RFP because: It is seeking more than $100,000 in program support Of state, Tribal, or local procurement rules It is seeking support for infrastructure The applicant has elected to use an RFP Transmission of large files (e.g., X-ray images, MRI, etc.) Other (describe): _____________ Category: Bulk Electronic patient billing Exchange of electronic health records Transmission of large files (e.g., X-ray images, MRI, etc.) Transmission of store and forward consultations Other (describe): _____________ Category: Miscellaneous Backup/redundant connectivity Other (describe): _____________ 12b Applicant requesting services for an off-site data center: Yes No If yes, provide HCP Number: 12c Applicant requesting services for an off-site administrative office: Yes No If yes, provide HCP Number: 13 Contact for Request for Services: Same as HCP Physical Location Contact Same as HCP Primary Account Holder Other 13a If other, provide full contact information: Contact Name Organization Name Contact Name Title Phone Ext. Email DR AF T FCC Form 461 Block 4: Declaration of Assistance 20 Have any consultants, service providers, or any other outside experts, whether paid or unpaid, aided in the preparation of the FCC Forms 460 or 461, RFP, bid evaluation, or network plan? Yes No 21 Organization Type: List the contact information for all consultants, service providers, and outside experts that assisted in preparing any part of the FCC Forms 460, 461, RFP, bid evaluation, or network plan. a. Name (First, Middle Initial, Last) b. Organization Type c. Title/Role d. Employer e. Address Line 1 f. Address Line 2 g. City h. State i. Zip Code Block 5: Bid Evaluation 22 Select selection criteria (and weights assigned to each) that will be used to evaluate bids received as a result of this request for services. Attach supplemental information (if necessary). Criteria Weight a. b. c. Block 7: Certifications 24 I certify under penalty of perjury that I am authorized to submit this request on behalf of the health care provider or consortium. 25 I declare under penalty of perjury that I have examined this form and attachments and to the best of my knowledge, information, and belief, all information contained in this form and in any attachments is true and correct. 26 I certify under penalty of perjury that the applicant has followed any applicable state, Tribal, or local procurement rules. 27 I certify under penalty of perjury that the supported connection(s) and network equipment will be used solely for purposes reasonably related to the provision of healthcare service or instruction that the health care provider is legally authorized to provide under the law of the state in which the connections are provided. In addition, I certify under penalty of perjury that the supported connection(s) and network equipment will not be sold, resold, or transferred in consideration for money or any other thing of value. Block 6: Additional Documentation 23 List all supporting documentation (RFP, Network Plan, etc) that is required to be submitted with this form. Type of Documentation a. b. c. 18 Description of Services Requested (Required to provide a summary of RFP if submitting one): 19 Contact for Request for Services: Same as Project Coordinator Same as Assistant Project Coordinator Other 19a If other, provide full contact information: Contact Name Organization Name Contact Name Title Phone Ext. Email DR AF TPersons 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 461 Block 7: Certifications 28 I certify under penalty of perjury that the applicant satisfies all of the requirements under section 254 of the Communications Act, 47 U.S.C. § 254, and applicable Commission rules. 29 I certify under penalty of perjury that the applicant has reviewed all applicable requirements for the program and will comply with those requirements. 30 I understand that all documentation associated with this form, including a copy of the signed 461, any bids/ contracts resulting from the 461 posting, scoring sheet, and other information that was used in the decision making process, 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. 31 Signature 32 Date 33 Printed Name of Authorized Person 34 Title/Position of Authorized Person 35 Phone Ext. 36 Email 37 Employer 38 Employer’s FCC RN