Rural Health Care

Step 5: Submit Service Agreement Form

Once the service providers and services are selected, the health care provider completes and submits a Funding Request and Certification Form (Form 466) and/or an Internet Service Funding Request and Certification Form (Form 466-A) as well as a copy of the bill that indicates the charges for these services.

The Forms 466 and 466-A specify the type(s) of service ordered, cost, service provider(s), terms of service agreements, and certifies that the selections were the most cost-effective offers received.

Health care providers may request telecommunications support based strictly on their circuit distance (mileage-based charges) or may request support based on the difference between what they pay and what an equivalent circuit would cost in any city with a population of 50,000 or more in the health care provider's state. Health care providers requesting support for Internet access charges will receive support for 25% of the monthly Internet charges, if eligible.

In order to obtain the information and documents necessary to complete Forms 466 and 466-A, the health care provider may need to work with a representative of the selected service provider. The service provider representative may need to provide detailed circuit information, a circuit diagram, a documented urban rate, or contract information.

All certification boxes must be checked on Form 466 and 466-A. Paper Form 466 and 466-A submissions must have a dated original (not photocopied) signature of an authorized person. E-certification may be used for Form 466 and 466-A submitted through the USAC website.

Upon completion of Form 466 and/or 466-A and all related documentation, the health care provider mails all documents to USAC for review. A Form 466 and/or 466-A submitted through E-certification requires supplemental documentation to be sent to USAC by mail. Forms with missing or incomplete information or documentation cannot be processed.

USAC reviews the form(s) and supporting documentation, collectively known as a "packet," for accuracy. If USAC has questions about the packet, the health care provider or service provider will be contacted. Health care provider and service provider representatives are strongly encouraged to respond to USAC inquiries in a timely manner to expedite processing of the application.


Last modified on 2/19/2008