Funding Year 1999
Process Overview
Frequently Asked Questions
New & Noteworthy
Funding Commitments
Health Care Provider Area
Eligible HCPs
Eligible Services
List of Rural Areas
HCP Forms
Reimbursement Process
Appeals Process
Telecommunications
Carrier Area
Eligible Telco Carriers
Search Postings
Telco Forms
Invoicing
RHCD Info
About the RHCD
RHCD Training
More Info
Telemed & Telehealth
Related Links
Customer Service
Support Center
Contact Information
Internal Use Only
Customer Service Access
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Form 468 "EZ" Step-by-Step Instructions
Please print
this page and refer to the following instructions. Make sure that
you are completing the correct Form 468. There are significant
differences between the Funding Year 1998 and 1999 forms. The
Funding Year 1999 Form 468 has an "October 1998" date
on the bottom right corner of the form.
Each Block and
number coincide with the Block and number items on the
application. If you are filing electronically, you can save your
form to edit it at a later time. With the exception of the HCP
Number, all fields are editable.
A separate
Form 468 must be submitted for each telecommunications carrier
and each service ordered. For example, if you are one of multiple
carriers providing a T1 line, each of the involved carriers must
submit a Form 468. If you are providing a HCP with multiple
services of different types (e.g., ATM and ISDN line), a Form 468
must be submitted for each different service. If there is
confusion about the number of Form 468s that should be submitted,
contact the Customer Service Support Center at 1-800-229-5476 for
clarification.
Block
1: Health Care Provider Information
Items 1
through 4 must match the HCP's Form 465.
- Check the
1999 box. The 1999 Funding Year begins on July 1, 1999
and ends on June 30, 2000. Currently, the RHCD is not
accepting applications for Funding Year 2000.
- Enter
your customer's HCP Number. You can find the number on
the HCP's Form 465 or you may contact your customer
(i.e., the HCP) for this number.
- Enter the
HCP Name. The name must match the name provided on Form
465.
- Enter the
HCP Federal EIN. It is a nine-digit number that follows
this convention: 12-3456789. The number must match the
number provided on Form 465. You can find the number on
the HCP's Form 465 or you may contact your customer
(i.e., the HCP) for this number.
Block 2:
Telecommunications Carrier Information
- Enter the
name of the telecommunications carrier with whom the HCP
contracted for supported services. Write the complete
name - do not abbreviate.
- Enter the
telecommunications carrier's Service Provider
Identification Number (SPIN). If the carrier is a
subsidiary or division of another carrier, make sure the
SPIN for the contracted carrier is entered. The SPIN is a
nine-digit number that begins with 143.
- Enter the
telecommunications carrier's street address.
- If
necessary, use this line for additional street address
information.
- Enter the
city that corresponds to the carrier's street address in
item 7.
- Enter
the state that corresponds to the carrier's city in item
9.
- Enter
the ZIP code that corresponds to the carrier's city and
state in items 9 and 10.
Block 3:
Telecommunications Carrier Invoicing Information
After a HCP is approved to receieve support, telecommunications carriers will
provide support on the HCP's telecommunications bill and invoice RHCD for the amount credited. Enter your company's contact information
for the invoicing process in Block 3.
- Enter the
telecommunications carrier's point of contact for
Universal Service Fund (i.e., RHCD) invoicing.
- Enter the
phone number for the contact person listed in item 12.
Remember to include the area code.
- Enter the
invoicing contact person's e-mail address, if applicable.
- Enter the
invoicing contact person's street address if different
from item 7.
- Enter the
invoicing contact person's street address if different
from item 8.
- Enter the
invoicing contact person's city if different from item 9.
- Enter the
invoicing contact person's state if different from item
10.
- Enter the
invoicing contact person's ZIP code if different from
item 11.
- Enter the
contract or tariff number (whichever one applies) for the
service provided to the HCP listed in item 3. Enter
"n/a" if the HCP is only requesting support for
toll or long distance charges to access the Internet, and
there isn't a contract or tariff number. Proceed to Block
4.
Block 4:
Internet Access Support
- Check
"yes" if support for providing toll-free
Internet access to a HCP is requested. Check
"no" if Internet access support is not
requested. If "yes", proceed to Block 7.
Block 5: Bill
Circuit Information
- Choose
only one box - "single bill circuit" or
"multiple bill circuit". If more than one
carrier is required to complete a circuit, and each
carrier bills the HCP separately, select "multiple
bill circuit". If "single bill circuit",
proceed to Block 6. If "multiple bill circuit",
complete the fields in item 23.
- List the
names and SPINs of all the telecommunications carriers
who provide a portion of the HCP's circuit.
Block 6:
Calculation of Rates
The RHCD
recommends that telecommunications carriers use the Form 468
Worksheet to calculate rates. If the carrier cannot access the
Worksheet, it can use the Form 468 Worksheet "EZ"
Step-by-Step Instructions to calculate the required rates.
Clearly labeled back-up calculations must be attached, regardless
of the method used.
- Enter the
Per Location Funding Limit (PLFL). The PLFL is the
maximum amount of support an HCP may receive during the
funding year. It is equal to the support for a point to
point T1/1.544 Mbps circuit over the Maximum Allowable
Distance (calculated and posted on Form 465). The PLFL
must be calculated if a service other than a T1 is
requested. The Form 468 Worksheet calculates the PLFL.
Review the Form 468 official OMB instructions for more
information.
- Enter the
type of service provided or to be provided to the HCP
named in item 4.
- Enter the
quantity of the service listed in item 25.
Enter the
circuit distance for the service named in item 25. The
circuit distance is the total distance, in miles, for the
circuit. The circuit distance starts and ends at the
first and last point mileage charges are incurred.
Enter the
Billing Telephone Number (BTN) for the service listed in
item 25. This is an optional field.
Items 29
through 32 require the telecommunications carrier to enter the
estimated support amounts. The Form 468 Worksheet includes all
four items.
- Enter the
estimated non-recurring support amount.
"Non-recurring" indicates a one-time charge
such as service installation. The support amount is equal
to the difference between the rural rate (amount the HCP
is charged) and the urban rate. Review the Form 468
official OMB instructions for more information.
Enter the
number of months the service will be effective during the
1999 funding year. Round up to whole months.
Enter the
estimated monthly recurring support amount. The support
amount is equal to the difference between the rural rate
(amount the HCP is charged) and the urban rate. Review
the Form 468 official OMB instructions for more
information
Enter the
estimated support for the 1999 funding year. Use this
formula: item 29 + (item 30 x item 31).
Block 7:
Certification Statement
- Read both statements and check only one box.
- Read this statement and check this box only if the HCP is a member
of a consortium
- Read this statement and check the box.
- Sign Form 468. You must submit an original signature - not a photocopied signature - to RHCD.
- Date Form 468.
- Print your name.
- Print your title or position.
If you
are completing Form 468 electronically, submit the form,
print it out, sign, date, and mail the form, along with
your Form 468 Worksheet or rate calculations to the HCP.
The HCP is responsible for forwarding all Form 466 and
Form 468 documentation to the RHCD.
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