Form 465 Instructions

Purpose of Form

FCC Form 465 is the first step a health care provider (HCP) must take in order to benefit from the universal service support mechanism. Universal service support allows eligible health care providers to purchase certain services at reduced rates. Form 465 is the means by which a health care provider:

1. Requests bids for the provision of telecommunications or Internet services from service providers.
2. Certifies to the Rural Health Care Division of the Universal Service Administrative Company, which serves as the administrator, that the health care provider is eligible to benefit from the universal service support mechanism.

Health care providers who have previously posted a Form 465 can register for electronic certification. Electronic certification allows the health care provider to electronically sign the new Form 465 so it can be immediately posted on the RHCD web site.

After the health care provider submits a Form 465, the Rural Health Care Division (RHCD) will post the completed Form 465 on its web site. The posted Form 465 provides information about the HCP and its need for services to service providers that might wish to bid to provide the services.

Each health care provider’s Form 465 must be posted on the RHCD website for at least 28 days prior to selecting a service provider, to fulfill the program’s competitive bidding requirement.

Rural health care providers may enter into agreements to purchase services after 28 days have elapsed since the descriptions set forth in Form 465 were posted on the RHCD web site. Entering into any agreement during the 28-day posting period is prohibited.

RHCD will send each applicant a “Receipt Acknowledgement Letter” confirming that its Form 465 is posted on the web site. The confirmation of posting sent by RHCD will indicate the date on which the health care provider may enter into an agreement to purchase services from a service provider. This date is known as the Allowable Contract Selection Date (ACSD).

The health care provider must select the most cost-effective service or services. "The most cost-effective service" is defined in the Universal Service Order as the service available at the lowest cost after consideration of the features, quality of transmission, reliability, and other factors that the health care provider deems necessary for the service to adequately transmit the health care services required by the health care provider. This requirement is reiterated for Internet service in the Rural Health Care Order.

After the HCP enters into an agreement, it must initiate the next step in the application process, the filing of an FCC Form 466 (Funding Request and Certification Form).

Filing Requirements and General Instructions

¹ Federal-State Joint Board on Universal Service, CC Docket No. 96-45, Report and Order, 12 FCC Rcd 8776, 9134 (1997), as corrected by Federal-State Joint Board on Universal Service, Errata, CC Docket No. 96-45, FCC 97-157 (rel. June 4, 1997), affirmed, reversed, and remanded in part sub nom. Texas Office of Public Utility Counsel v. FCC, 183 F.3d 393 (5th Cir. 1999), motion for stay granted in part (Sept. 28, 1999), petitions for rehearing and rehearing en banc denied (Sept. 28, 1999) (Universal Service Order).

² Federal Communications Commission, Report And Order, Order On Reconsideration, and Further Notice Of Proposed Rulemaking, WC Docket No. 02-60, Adopted November 13, 2003 (Rural Health Care Order).

Who is Eligible

A health care provider must meet two criteria in order to benefit from the universal service support mechanism.

It must be a public or non-profit health care provider that falls within one of the following categories:

• Post-secondary educational institution offering health care instruction (including teaching hospitals and medical schools)
• Community health center or health center providing health care to migrants;
• Local health department or agency;
• Community mental health center;
• Not-for-profit hospital;
• Rural health clinic;
• Consortium of health care providers consisting of one or more of the above entities;
• Dedicated emergency department of for-profit hospitals, including Critical Access Hospitals;
• Part-time eligible entity.

Health care providers that do not fall into one of these categories are not eligible to benefit from the universal service support mechanism.

With one exception, (long distance toll charges to reach the Internet, as described below), a health care provider must be located in a rural area to qualify for support.

A health care provider can determine whether it is located in an area that falls within the Federal Communication Commission's definition of "rural area" by consulting the RHCD web site. A health care provider may also call the Rural Health Care Division at 1-800-229-5476 for assistance in making this determination.

Health care providers that meet both of the eligible category and rural criteria are considered "eligible health care providers."

Urban Exception - A public or non-profit health care provider that qualifies in one of the categories listed above, but is not located in a rural area, may receive the lesser of $180 or 30 hours per month of support for toll (long distance) charges necessary to connect to an Internet service provider. This is the only exception to the requirement that a health care provider be located in a rural area to benefit from the universal service support mechanism, and it only provides for support of toll charges, not Internet access charges.

Filing Exception - The filing of a Form 465 may not be required if the HCP is receiving services under a currently valid contract executed pursuant to a Form 465 posted in a prior program year, or if services are received under a contract signed on or before July 10, 1997. A renewed contract or a contract with an automatic renewal provision is considered a new contract on the renewal date, and an expired contract is not considered a currently valid contract. Questions about the status of an HCP’s contract may be directed to RHCD at 1-800-229-5476. Applicants who are not required to file a Form 465 must still submit a Form 466 for each program year covered by the contract.

Where to File

The FCC Form 465 must be filed with the Rural Health Care Division at:

Rural Health Care Division
80 South Jefferson Road
Whippany NJ 07981

The health care provider may also file this form electronically. Instructions on how to file electronically are posted on the RHCD web site. DO NOT FILE THIS OR ANY OTHER UNIVERSAL SERVICE FORM WITH THE FEDERAL COMMUNICATIONS COMMISSION.

Compliance

Anyone filing false information may be subject to penalties for false statements, including fine or forfeiture, under the Communications Act, 47 U.S.C. 502, 503(b), or fine or imprisonment under Title 18 of the United States Code, 18 U.S.C. 1001.

Where to Get More Information

Call the Rural Health Care Division at 1-800-229-5476 for more information on how to complete this or other universal service forms. Information is also available on the RHCD web site.

Specific Instructions for Filing Form 465

Type or print clearly in spaces provided. Attach additional sheets if necessary. Applicants are also encouraged to complete this form electronically to speed up the processing of applications. RHCD will post all applications on the RHCD web site. Instructions on how to file electronically are posted on the web site.

Form 465 Application Number

The RHCD will insert the Form 465 Application Number (known in prior years as the "Universal Service Control Number"). Leave this line blank.

Block 1: HCP Location Information
The information required in this block applies to the physical location of the HCP. Do not enter a “PO Box” or “Rural Route” address.

Line 1 requires providing an HCP number. The HCP number is a unique identifier given by RHCD to each health care provider applying for benefits. If the HCP previously applied for benefits from universal service support, RHCD has already assigned it a number, which must be used here. If it is uncertain whether the HCP has previously been given a number, call the Rural Health Care Division at 1-800-229-5476. RHCD will assign an HCP number to each new applicant upon receipt of the Form 465.

Line 2 requires identifying the name of the consortium to which the HCP belongs, if any. (If the HCP does not belong to a consortium, leave Line 2 blank.)

Line 3 requires providing the health care provider’s organization name. This name must be used consistently on all universal service forms (i.e., Form 465, Form 466, Form 466-A, & Form 467).

Line 4 requests entering an Applicant Form Identifier if the applicant is filing more than one Form 465. Please use this space to assign a number or letter of the applicant’s choice to facilitate communication with RHCD about this particular Form 465. This Applicant’s Form Identifier may be simple; for example, if filing multiple versions of Forms 465, they might be labeled “A,” “B,” and “C.” Create identifiers that suit the applicant’s record-keeping needs.

Line 5 requires providing the name of a contact person at the health care provider’s location. This person should be able to answer questions regarding and/or verify the information submitted on this form, in the event that RHCD needs to contact the HCP during the application process.

Lines 6-13 require providing the contact person’s telephone number; mailing address including city, state, and ZIP Code; email address; and fax number.

Line 14 requires identifying the county in which the HCP is located.

Block 2: HCP Mailing Information

Line 15 requires indicating whether or not the HCP’s mailing address is different from the address in Block 1. If “No” is checked, skip the remainder of Block 2 and proceed to Block 3.

Line 16 requires identifying the name of the organization to receive mail regarding the Form 465.

Line 17 requires providing the name of the contact person at the organization identified in Line 16.

Lines 18-25 require providing the contact person’s telephone number; mailing address, including city, state, and ZIP Code; email address, and fax number.

Block 3: Funding Year Information

Line 26 requires identifying the funding year for which the HCP is applying. The applicant should check only one box.

Block 4: Eligibility

Line 27 requires checking the box indicating the eligibility category of the HCP. Only public or non-profit health care providers located in rural areas that fall into one of the categories listed in Line 27 are eligible to benefit from this universal service support mechanism. Applicants must be non-profit or public government entities except for for-profit hospital emergency departments, which the FCC clarified in the Rural Health Care Order, are “public” by virtue of their requirement to examine or treat patients pursuant to the Emergency Medical Treatment and Labor Act (EMTALA).

Note that applicants that apply as consortium of health care providers may only receive support for services provided to the physical location given in Block 1, meaning that unless the “above entities” are at that address, they will not be able to receive support. Rather, a separate Form 465 should be filed for each eligible entity in the consortia, using that entity’s address, so it can be verified as rural and the Maximum Allowable Distance determined. Applicants selecting the consortium category must complete Line 28, and may call RHCD at 800-229-5476 for further explanation of their eligibility.

The categories of “Dedicated emergency department of rural for-profit hospitals including Critical Access Hospitals” and “Part-time eligible entity” were defined in the Rural Health Care Order, and are further discussed under “Eligibility and Support Percentage for For-Profit Hospital Emergency Department or Part-Time Rural Health Clinic” on the RHCD website at www.rhc.universalservice.org. Applicants that select these categories should review the website material to determine that they qualify, and to recognize that they may only be eligible for partial support of their selected service. Applicants selecting these categories must complete Line 28, and may call RHCD at 800-229-5476 for further questions about eligibility.

Line 28 must be completed only if “Consortium of the above”, “Dedicated emergency department of rural for-profit hospitals including Critical Access Hospitals”, or “Part-time eligible entity” was selected in Line 27. A description of the entity and the services it provides is required.

Line 29 requires a description of how the health care provider is going to use the supported service. The purpose of this description is to allow service providers to learn what the health care provider wants to do, so they can propose services to meet the health care provider’s objectives. Some examples are transmission of data and medical images or X-rays; health care provider-to-provider consultation between professionals in a rural hospital and professionals in other locations, provider-to-patient consultation, examination, or counseling; medical research, access to the health care provider’s website, offsite storage of medical records, or other uses.

Block 5: Request for Services

Line 30 requires indicating whether the HCP is requesting support for a telecommunications service, Internet service, or both. An application must be posted for the type of service (telecommunications or Internet) for which support will be sought, e.g. an application posted only for telecommunications service would not be eligible to request support for Internet access. If additional guidance on eligible services is needed, please contact RHCD at 1-800-229-5476.

Block 6: Certification

Line 31 requires the person signing on behalf of the HCP to certify that he or she is authorized to submit the information contained in the Form 465 on behalf of the entity or entities (if applying as a consortium) applying for discounted services. The authorized representative signing on behalf of the applicant must certify that the information contained in Form 465 is true to the best of his or her knowledge, information and belief. Fine, forfeiture, or imprisonment can be used to punish persons willfully making false statements on this form under federal law.

Line 32 requires the authorized representative of the HCP to certify that any applicable state or local procurement rules have been followed.

Line 33 requires the authorized representative to certify that the services for which the health care provider receives a discount will not be used for unauthorized purposes. Specifically, the representative must certify that such services will be used solely for purposes reasonably related to the provision of health care service or instruction that the health care provider is legally authorized to provide under the law of the state in which the services are provided. The representative must also certify that the discounted services that the HCP receives will not be sold, resold, or transferred in consideration for money or any other thing of value.

Line 34 requires identifying whether or not the HCP is a non-profit or public entity.

Line 35 requires identifying whether or not the HCP is located in a rural area.

Visit the RHCD web site or contact RHCD at 1-800-229-5476 for a list of the rural areas.

Line 36 requires the authorized representative to certify that the HCP satisfies each of the specific requirements set forth in the Form 465 and that the HCP will abide by the relevant requirements of 47 U.S.C. § 254.

Line 37 requires the signature of the authorized representative certifying the information contained in Form 465 on behalf of the applicant.

Line 38 requires the date the Form 465 was signed.

Line 39 requires the printed name of the authorized representative certifying the information contained in Form 465 on behalf of the applicant.

Line 40 requires the title or position of the authorized representative certifying the information contained in Form 465 on behalf of the applicant.

Reminders

• Health care providers seeking to benefit from universal service support must file an FCC Form 465.
• The representative authorized to provide the information required by FCC Form 465 on behalf of a health care provider must sign and date FCC Form 465.
• Provide data for all items that apply. Attach additional sheets if necessary. Any attachments to FCC Form 465 must be clearly labeled.