Submission Materials

The COVID-19 Telehealth Program application is designed to obtain information that will be used to evaluate and select applications from Health Care Providers (HCPs) to receive funding for telehealth services and devices. The information is necessary to confirm eligibility, prioritize applications based on the objective evaluation criteria adopted by the Commission, and determine funding award amounts.

The application will be live for the duration of the application window, from April 29, 2021 at 12 p.m. ET to May 6, 2021 at 12 p.m. ET. No application decisions will be made until the window closes.

Below is an overview of what information you can expect to see on the COVID-19 Telehealth Program application form.

General Information

• Applicant Name
• Applicant FCC Registration Number
• Applicant National Provider Identifier (NPI)
  • The National Provider Identifier (NPI) is a Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Standard. The NPI is a unique 10-digit identification number for covered HCPs. Learn how to apply for an NPI on the Centers for Medicare & Medicaid Services website.
• Taxpayer Identification Number (TIN)/Employee Identification Number (EIN)
• DATA Act Business Type
  • From the Data Accountability and Transparency (DATA) Act Business Types
  • Applicants may provide up to three business types
  • View a list of Business Types to choose from
• Service Area
  • Applicants must enter their primary service area state, territory, District of Columbia, or “nationwide.”

Contact Information

• Contact information for individuals responsible for the application, including one primary contact and a project manager contact:
  • Name
  • Position Title
  • Company Name
  • Phone Number
  • Mailing Address
  • Email Address
  • Project Manager Name
  • Project Manager Phone Number
  • Project Manager Email Address

Note: These individuals should be prepared to field requests for additional information regarding the application during the application review process. The reviewer may reach out to applicants with questions about the lead health care provider’s eligibility, about the information listed under the evaluation metrics section, about the services and connected devices listed in the Funding Request Detail section of the application.

Health Care Provider (HCP) Information

The lead HCP information is required, and the applicant can choose to add other HCPs associated with the application. For each HCP affiliated with the application, you may provide, but are not required to, the following information in the HCP Tab of Application:

• HCP Number from the FCC Form 460
• Facility Name
  • The Lead HCP is required; the applicant may choose to provide information for any or all HCPs associated with the application
• Whether it is the Lead HCP
• Street address, city, state, county
• Whether the Facility is a Hospital
• Total Patient Population
• Estimated Number of Patients to be Served by Funding Request
• FCC Registration Number (FRN) (optional)
• Eligibility type (optional)
• National Provider Identifier (NPI) (optional)

Supporting Information

Evaluation Metrics

Under the “Evaluation Metrics” section, the applicant must list the following information for the HCP that qualifies for each metric if they wish to receive points for that metric:

• Round 1 Application Number (GRA00XXXX) for previous applicants
• Physical address and county for rural, low-income, Critical Access Hospital (CAH), and entities that qualify for the Tribal area metric and for health care providers in “hardest hit” areas
  • Supporting documentation is needed for entities that are seeking points based on Tribal affiliations
• Critical Access Hospital (CAH) Certification Number for CAHs
• Primary Care Healthcare Provider Shortage Area (HPSA) ID or Primary Care Score for entities in Healthcare Provider Shortage Areas
• Federally-Qualified Health Center (FQHC) ID, Bureau of Primary Health Care Health Center Management Information System ID (BHCMISID), Uniform Data System (UDS) number, or CMS Certification Number for FHQCs, FQHC Look-Alikes, and Disproportionate Share Hospitals (DSH)

Purpose and Intent

• Whether the applicant will treat COVID-19 patients directly
• Whether the applicant will treat patients without COVID-19 symptoms

Funding Request

• Total amount of funding requested (auto-calculated from Funding Request Details line items)
• Whether funding for devices is being requested
• Funding Request Details is in a separate section of the application, but is associated with the Funding Request tab. Information requested in Funding Request Detail section:
  • Category
  • Description of service(s) and/or device(s)
  • Quantities of services or devices
  • Total one-time expense
  • Total monthly expense
  • Expense date purchased or to be purchased
  • Service dates for recurring services (optional)

Applicants must provide supporting cost documentation (e.g., an invoice or a vendor quote) for all eligible services and devices for which funding is requested.  Applicants must provide the following information for each service or connected device so that reviewers can determine whether the items are eligible. The supporting documentation should be attached with the corresponding line item in the Funding Request Detail Section.