Form 467 Instructions

Purpose of Form 467

Form 467 is used by a health care provider (HCP) to notify the Rural Health Care Division (RHCD) of the Universal Service Administrative Company that the service provider began providing the telecommunications or Internet services for which the HCP is seeking to receive the benefit of reduced rates through the rural health care universal service support mechanism. It is the last form required in the application process. This form is also used to notify RHCD when the HCP has discontinued the service (i.e., service is turned off), or that service was not (or will not be) turned on during the funding year. An applicant must submit one Form 467 for each Funding Request and Certification Form (Form 466) or Internet Service Discount Request (Form 466-A) that it submitted to RHCD.

An HCP will not receive benefits from this universal service support mechanism until RHCD receives the completed Form 467.

Filing Requirements And General Instructions

Who Must File

The HCP or its authorized representative must file a Form 467 to certify that the service provider began providing the service (i.e., the service is turned on), or to notify RHCD that the service provider has ceased to provide service that the HCP had been receiving at reduced rates as a result of its participation in this program, or to inform RHCD that service was not (or will not be) turned on during the funding year.

HCPs cannot receive support directly from the Universal Service Fund. Rather, HCPs may receive the benefit of reduced rates for telecommunications and Internet services from their selected service providers, who will be compensated for those reduced rates by the universal service support mechanism.

When to File

The HCP or its authorized representative must file Form 467 after it has filed a Form 466 or a Form 466-A and the service provider(s) has begun to provide the service (i.e., the service is turned on). The HCP or its authorized representative must also file Form 467 when the service provider has ceased to provide service that the HCP had been receiving at reduced rates as a result of its participation in this program.

The HCP or its authorized representative must submit a separate Form 467 for each Form 466 or Form 466-A that it previously submitted to RHCD.

Where to File

A paper copy of Form 467 with an original signature or an electronically certified Form 467 must be submitted for each service requested. (See RHCD web site, for instructions on Electronic Certification of Form 467). Applicants are encouraged to complete Form 467 on the RHCD web site, but unless the applicant has been approved for E-Certification, a Form 467 completed on the web site MUST BE PRINTED, SIGNED, and SUBMITTED to the address provided below.

Rural Health Care Division
80 S. Jefferson Road
Whippany, NJ 07981

DO NOT FILE THIS OR ANY OTHER UNIVERSAL SERVICE FORM WITH THE FEDERAL COMMUNICATIONS COMMISSION.

Compliance

HCPs that fail to file Form 467 will not receive benefits from this universal service support mechanism. 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 RHCD at 1-800-229-5476 for more information on how to complete this and other universal service forms. Information is also available on the RHCD web site.

Specific Instructions

Type or print clearly in spaces provided. Attach additional sheets if necessary.

Block 1: HCP Information
Block 1 will help the applicant and RHCD identify and match up Form 467 with previous forms that have been filed on behalf of the HCP.

Line 1 requires providing the HCP’s name. This name must be used consistently on all universal service forms (i.e., Form 465, 466, 466-A and 467). The HCP name should match the HCP name supplied in Line 3 of the Form 465.

Line 2 requires providing the name of the consortium, if the HCP is a member of a consortium. If the HCP is not a consortium member, Line 2 should be left blank.

Line 3 requires providing the HCP number. The HCP number is a unique identifier given by RHCD to each HCP applying for benefits. RHCD assigns an HCP number to each new applicant upon receipt of Form 465. This number is in the funding commitment letter that you received from RHCD, and should match the HCP number in Line 1 of Form 465.

Block 2: Bill Payer Information

Line 4 requires providing the billed entity’s name. The “billed entity” is the entity that actually pays the bills of the service provider for the HCP. It may be the HCP itself, or it may be a “parent” organization or consortium to which the HCP belongs. The information in Line 4 of Form 467 must match the information provided in Block 2 Line 6 of the Form 466 or Form 466-A.

Line 5 requires identifying the name of a contact person at the billed entity location. This person should be able to answer questions or verify the information submitted on this form, in the event that RHCD needs to contact the billed entity during the application process.

Line 6 requires providing the contact person’s telephone number.

Block 3: Funding Year Information

Line 7 requires providing the funding year (July 1 through June 30) for which the HCP is requesting support. Check ONLY one box. This information should match the information in Block 3 of the Form 465 for the same funding year.

Block 4: Action Taken

Block 4 of Form 467 is used to confirm that the HCP is receiving the service for which it is requesting a discount, and in the event that the service is discontinued, to notify RHCD of the date of disconnection so that RHCD can arrange for termination of the discount. HCPs must promptly report to RHCD all connections and disconnections.

Line 8 requires identifying the purpose for which this form is being used. If confirming the connection of a service, check the first box in Line 8. If notifying RHCD of the disconnection of a service, check the second box in Line 8 and enter the effective date of the disconnection. If notifying RHCD that the requested service was never turned on (or will not be turned on) during the funding year, check the third box in Line 8.

Block 5: Connection Information

For Telecommunications Service - Block 5 requires information about each of the connections that together comprise the entire circuit for telecommunication service. The telecommunication connection information in Block 5 (Lines 10, 11, 12, and 13) of Form 467 must match the information provided in Block 4 (Lines 21, 22, 28, and 17) of Form 466. Most circuits only contain one connection (i.e., one telecommunications carrier provides the entire circuit), in which case only the first column should be completed. However, some circuits have multiple connections and multiple bills (i.e., more than one telecommunications carrier) for the same circuit. This form accommodates information for up to three connections. The information for each connection should be entered in separate columns. Telecommunications Carrier A must be the carrier that provides the segment of the circuit connecting directly to the HCP. Telecommunications Carrier B should be the carrier that provides the next segment, and Telecommunications Carrier C is the furthest from the HCP. If the circuit contains more than three connections, please call RHCD at 1-800-229-5476.

For Internet Access Service - Only the first column should be completed. The Internet connection information in Block 5 (Lines 10, 11, and 12) of Form 467 must match the information provided in Block 4 (Lines 20, 21, and 22) of Form 466-A, and the service type on Line 13 must be “Internet”.

Line 9 requires providing a funding request number. The funding request number is a unique identifier assigned by RHCD for each discounted service requested by the HCP. This number is in the funding commitment letter that RHCD previously sent.

Line 10 requires providing the full legal name of the service provider providing the connection. HCPs must provide a service provider name for each connection.

Line 11 requires entering the 9-digit Service Provider Identification Number (SPIN) for the service provider(s) listed in Line 11. Each service provider should provide its SPIN upon request.

Line 12 requires providing the account number that the service provider has created to bill for the services provided to the HCP.

Line 13 requires identifying the services for which the HCP is seeking the benefits of reduced rates, and the circuit bandwidth if applicable. For Internet access enter “Internet”.

Line 14 requires providing the actual start date for each service .

Line 15 requires the date service was or will be disconnected, if this form is being submitted to notify RHCD that the service provider has ceased to provide the discounted service to the HCP. If there are no plans to disconnect the service, leave this item blank.

Block 6: Certification

Line 16 requires certification that the service(s) identified above have been or are being provided to the HCP. It also requires certification that the person signing the Form 467 is authorized to submit the information contained in this Form 467 on behalf of the HCP. The person signing must certify that the information contained in this Form 467 is true to the best of his/her knowledge, information, and belief. Persons willfully making false statements on this form may be punished by fine, imprisonment, or forfeiture under federal law.

Line 17 requires certification that the HCP satisfies each of the specific requirements set forth in the Form 467 and its instructions, and that the HCP will abide by all relevant requirements of 47 U.S.C. Sec. 254.

Line 18 requires the authorized person to sign his/her name to certify all of the information contained in Form 467 and all attachments.

Line 19 requires the authorized person to identify the date that the Form 467 was signed.

Line 20 requires the printed name of the authorized person signing Form 467.

Line 21 requires the authorized person signing to identify his/her title or position.