COVID-19 Update: USAC remains open for business—Washington, DC office closed. Learn more about USF program responses

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

Download Blank FCC Form 460

Submit a New 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 460 Guide – Data Centers and Admin Offices

FCC Form 460 Guide – Ineligible Site

FCC Form 461

Download Blank FCC Form 461 (FY2021)

Download Blank FCC Form 461

Request for Services Form

FCC Form 461 Guide – Individual HCP

FCC Form 461 Guide – Consortium

FCC Form 462

Download Blank FCC Form 462

Funding Request Form

FCC Form 462 Guide – Single Expense Individual HCP

FCC Form 462 Guide – Multi Expense Individual HCP

FCC Form 462 Guide – Consortium

FCC Form 463

Download Blank FCC Form 463

Invoice and Request for Disbursement Form

FCC Form 463 Guide – Health Care Provider

FCC Form 463 Guide – Service Provider

Telecom Program Forms

FCC Form 465

Download Blank FCC Form 465

Description of Services Requested and Certification Form

Community Mental Health Center Checklist

FCC Form 465 Guide

FCC Form 466

Download Blank FCC Form 466

Funding Request and Certification Form

FCC Form 466 Guide

FCC Form 467

Download Blank FCC Form 467

Connection Certification Form

FCC Form 467 Guide

Telecom Invoice Guide (Service Providers Only)

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 Help Desk at RHC-Assist@usac.org or at (800) 453-1546 to make alternative arrangements.