Fcc Form 460 - Rural Health Care (Rhc) Universal Service - Eligibility And Registration Form
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3FCC Form 460
OMB Approved 3060-0804
Estimated Time Per Response: 1 hour
Rural Health Care (RHC) Universal Service
Eligibility and Registration Form
Read instructions thoroughly before completing this form. Failure to comply may cause delayed or denied funding.
Block 1: General Information
1 Date Submitted:
Determine eligibility of an HCP site
Register an ineligible site
2 Applying to:
Determine eligibility of Consortium
Register an off-site administrative office
Register an off-site data center
2a If applying as an off-site data center, list all sites (eligible and ineligible) that will use the services of this data center.
2b If applying as an off-site administrative office, list all sites (eligible and ineligible) that will use the services of this
administrative office.
Block 2: Site Information – Physical Site
Enter the actual physical location of the site.
3 HCP Number
4 Site Name
5 Name of Legal Entity
6 Enter FCC Registration Number (FCC RN) for Line 5 legal entity:
6a If the Line 5 legal entity does not have an FCC RN and only plans to participate as a consortium member, applicant
may enter FCC RN for the Consortium
:
(see instructions for more detail)
7 Site Contact Name
8 Address Line 1
9 Address Line 2
10 County
11 Geo Location (if no street address)
12 City
13 State
14 Zip Code
15 Phone
Ext.
16 Email
Block 3: Consortium Information
17 HCP Number
18 Name of Consortium
19 Is the Consortium a legal entity?
Yes
No
If yes, Consortium FCC RN:
20 Consortium has a written agreement allocating legal and financial responsibility.
Yes
No
If yes, submit the agreement to USAC. If no, see instructions regarding the default entity that bears legal and financial responsibility for the
consortium’s activities in connection with the Healthcare Connect Fund.
21 Consortium Leader Type:
The Consortium
Ineligible State organization
An eligible HCP participating in the Consortium
Ineligible public sector (government) entity
HCP Number: ________________________
Ineligible non-profit entity
A state organization, public sector entity, or non-profit entity may obtain an exemption to allow the organization to perform vendor functions and
provide application assistance. Submit any such request for exemption.
22 Consortium Leader Contact Information
23 Name of Consortium Leader
Consortium applicants are required to have a Letter of Agency from each eligible HCP that authorizes the Consortium to file forms on the HCP’s
behalf. Submit a Letter of Agency for each eligible HCP.
24 List participating sites by HCP Number (eligible/ineligible)
Block 4: Contact Information
25 Primary Account Holder/Project Coordinator Name
26 Employer
27 Address Line 1
Same as Physical Location
28 Address Line 2
29 City
30 State
31 Zip Code
32 Phone #
Ext.
33 Email
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