Forms
All RHC program forms and supporting documentation must be submitted to USAC by filing online through My Portal. COVID-19 Telehealth Program applicants must use the FCC Form 460 below to seek an eligibility determination.
HCF Program Forms
| FCC Form 460
(COVID-19 Telehealth Program start here) |
Eligibility and Registration Form
Community Mental Health Center Checklist FCC Form 460 Guide – Individual HCP FCC Form 460 Guide – Consortium |
| FCC Form 461 | Request for Services Form |
| FCC Form 462 | Funding Request Form
FCC Form 462 Guide – Single Expense Individual HCP |
| FCC Form 463 | Invoice and Request for Disbursement Form |
Telecom Program Forms
| FCC Form 465 | Description of Services Requested and Certification Form |
| FCC Form 466 | Funding Request and Certification Form |
| FCC Form 467 | Connection Certification Form |
Please note that the RHC program application forms, which expired on December 31, 2016, were replaced with new OMB-approved forms in My Portal on January 1, 2017. Applicants should refer to My Portal for the most up-to-date application forms.
Service Provider and Contributor forms (FCC Forms 498, 499-A/Q).
Applicants without adequate Internet access to submit the forms online should contact the RHC Customer Service Center at RHC-Assist@usac.org or at (800) 453-1546 to from 8 a.m. – 8 p.m. ET Monday through Friday to make alternative arrangements. Use the RHC Customer Service Center Tip Sheet to learn about what the RHC Customer Service Center can and cannot help you with.