Fcc Form 460 - Rural Health Care (Rhc) Universal Service - Eligibility And Registration Form Page 2
ADVERTISEMENT
1
2
3Block 2: Site Information – Physical Site
34 Secondary Account Holder (Application Contact/Assistant Project Coordinator)
35 Employer
36 Address Line 1
Same as Primary Account Holder Address
37 Address Line 2
38 City
39 State
40 Zip Code
41 Phone #
Ext.
42 Email
Block 5: Eligibility Category
43 Select the category that describes the HCP site
(If seeking an eligibility determination for a Consortium, “Consortium of the above” will be automatically selected)
A. Community health center or health center providing health care to migrants
B. Community mental health center
C. Local health department/agency
D. Non-profit hospital
E. Part-time eligible entity located in an ineligible facility
F. Post-secondary educational Institution offering health care instruction, teaching hospital, or medical school
G1. Rural health clinic
G2. Is this a mobile rural health care provider?
Yes
No
H. Dedicated ER of rural, for-profit hospital
I. Consortium of the above
44 Provide a brief explanation of why this site qualifies as the organization type selected above:
Block 6: Additional Information
45 Non-Profit Tax ID (EIN):
46 National Provider Identifier:
47a Organization Taxonomy Code:
Explanation if necessary (see instructions)
47b Site Taxonomy Code:
Explanation if necessary (see instructions)
48 If a Non-Profit Hospital, is this a Critical Access Hospital?
Yes
No
49 If a Non-Profit Hospital, how many licensed patient beds are at the site?
_______________
50 Is the site location:
On Tribal lands
Otherwise affiliated with a Tribe
Operated by the Indian Health Service
N/A
51 [Reserved]
52 [Reserved]
Block 7: Certifications and Signatures
53
I certify that I am authorized to submit this request on behalf of the site or consortium.
I declare under penalty of perjury that I have examined this form and attachments and to the best of my
54
knowledge, information, and belief, all information contained in this form and in any attachments is true and
correct.
If applying as an individual health care provider site, I certify that the health care provider is a non-profit or
55
public entity and that the site is located in a FCC designated rural area, or is grandfathered rural pursuant to
47 C.F.R. Sec. 54.600(b)(2).
If applying as a consortium, I certify that the eligible health care providers participating in the consortium are
56
non-profit or public entities.
I understand that all documentation associated with this form must be retained for a period of at least five
57
years pursuant to 47 C.F.R. § 54.648, or as otherwise prescribed by the Commission’s rules.
If applying as a consortium, I understand I must obtain letters of agency from each consortium member that
58
grants me the authority to complete, sign, and submit all forms for the funding year(s) for which support is
sought.
FCC Form 460
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal