Oklahoma Telemedicine Affidavit in Support of Request for Special Universal Services Page 2
OKLAHOMA HEALTHCARE ENTITY – TELEMEDICINE
FAQs related to the Oklahoma Universal Service Fund Affidavit
Q 1: Why is the Public Utility Division of the Oklahoma Corporation Commission asking for this information?
A 1: This request is being made in order to update the information the Oklahoma Corporation Commission has regarding each healthcare entity that receives funding from the Oklahoma Universal Service Fund (“OUSF”). If your Internet service provider has a pending request for funding from the OUSF for Internet access to your healthcare entity, the information in the Affidavit will be used to evaluate that funding request. Additionally, for telemedicine recertification, this Affidavit must be completed and returned to the Public Utility Division no later than February 1 each year.
Q 2: Who applies for OUSF funding?
A 2: Your telecommunications carrier (Internet service provider) applies for funding on the healthcare entity’s behalf.
Q 3: What happens if you do not provide complete information or all of the requested documents?
A 3: We will use the information you provide to determine how much OUSF funding the healthcare entity should receive. If the information you provide is not complete or is insufficient to determine the funding, you may receive less funding than you are eligible for, or no funding at all.
Q 4: What happens to the information you provide?
A 4: All information you provide is subject to the Oklahoma Open Records Act, and some or all of the information you provide may be publicly filed under the Cause number assigned to any application for funding from the OUSF, or may be made available to anyone making an Open Records request.
Q 5: What is telemedicine recertification?
A 5: Pursuant to OAC 165:59-7-6(g), no later than February 1 of each year, each eligible healthcare entity that receives OUSF telemedicine funding must recertify for the purpose of determining their continued eligibility for OUSF funding. The annual recertification shall be in the form and content approved by the Director of the Public Utility Division and this Affidavit is that form and content.
Q 6: What happens if an eligible healthcare entity fails to file for recertification by February 1?
A 6: If the healthcare entity is not recertified for the current level of funding, then funding will be adjusted or will cease as of July 1 of the same calendar year. Each healthcare entity will receive a letter from the Public Utility Division no later than May 1 of each year, advising them of the OUSF Administrator’s determination regarding continued eligibility and bandwidth level.
Q 7: Who do you call if you have questions?
A 7: For general questions, contact the Public Utility Division at (405) 521-4114. If your telecommunications carrier has a pending application for OUSF funding, contact the Analyst assigned to your Cause / Application. To contact an Analyst, call (405) 521-4114 and ask to be connected to the Analyst assigned to your Application.
OKLAHOMA TELEMEDICINE AFFIDAVIT
IN SUPPORT OF REQUEST FOR SPECIAL UNIVERSAL SERVICES
Effective December 2015
Please be advised that this Oklahoma Telemedicine Affidavit in Support of Request for Special Universal Services (“Affidavit”), or for the purpose of annual Recertification, along with all requested information, must be received by the Public Utility Division (“PUD”) of the Oklahoma Corporation Commission (“Commission”).
The Affidavit will not be deemed complete until it has been responded to, in full, and all requested documents, and/or explanations have been returned to PUD. Pursuant to OAC 165:59-3-62(b), failure to provide any of the requested information may result in a loss or denial of funding from the Oklahoma Universal Service Fund (“OUSF”).
IMPORTANT: Be advised that any alteration(s) to this Affidavit, other than providing responses in the spaces provided, will result in the Affidavit being deemed incomplete.
DISCLOSURE: This document and all attachments may be filed in the Court Clerk’s office of the Commission in any Cause filed on behalf of the healthcare entity.
INSTRUCTIONS
· Do not alter the document except to provide responses in the spaces provided. Changes to the Affidavit, besides filling in the spaces, make the Application/Recertification incomplete.
· Complete the Affidavit in your word processing program and provide it as DOCX file type.
· Since Sections 11 and 12 include items that require initials, signatures, and/or notarization, pages containing Sections 11 and 12 should be scanned and e-mailed.
· Submit the completed document to your service provider. When completing this Affidavit for the purpose of Recertification, submit the completed document to .
· Depending on the purpose of this Affidavit, complete the Sections and provide the Attachments as noted:
o Application – A request for funding for a telemedicine line, after a change in service provider or as a result of an increase in bandwidth.
§ Complete all Sections
§ All Attachments are required (Section 10)
o Change Request – A request for administrative approval of a change in price or eligible bandwidth related to an approved circuit with the same service provider.
§ Complete Sections: 1, 3, 5, 6, 7, 8, 9, 10, 11, and 12
§ Required Attachments (Section 10): 4, 5, 6, 7, 8, 9, and 10
o Recertification – An annual confirmation of eligibility to receive OUSF payments and verification that payments are properly received and credited as determined in Commission rules and orders. This is required by February 1 of each year.
§ Complete Sections: 1, 2, 3, 4, 5, 6, 7, 9, 10, 11, and 12
§ Required Attachments (Section 10): 1, 2, 4, 5, 6, 8, 9, and 10
SECTION 1: HEALTHCARE ENTITY INFORMATION
1.1 Date of Affidavit:
1.2 Purpose of this Affidavit (See Instructions):
Choose Affidavit Purpose
1.3 Legal name of healthcare entity:
1.4 Operational name of healthcare entity:
1.5 Healthcare entity is owned by:
1.6 Healthcare entity is managed by:
1.7 Address of healthcare entity, as listed in the OUSF funding Application:
Address 1:
Address 2:
City: State: Zip:
1.8 Name of primary healthcare entity contact for questions regarding responses in this Affidavit: Please include title, postal mailing address, telephone number, and e-mail address.
Name: Title: Employer:
Telephone: E-mail:
Address 1:
Address 2:
City: State: Zip:
1.9 Name of individual signing this Affidavit on behalf of the healthcare entity (must be an employee of the healthcare entity): Please include title, postal mailing address, telephone number, and e-mail address.
Name: Title:
Telephone: E-mail:
Address 1:
Address 2:
City: State: Zip:
SECTION 2: ELIGIBILITY OF HEALTHCARE ENTITY
2.1 Does the healthcare entity have a certificate or license, which qualifies it as an eligible healthcare entity? (See Section 10, Question 10.1, Attachment 1.):
Choose Yes or No
2.2 Type of healthcare entity, pursuant to 17 O.S. § 139.102 and OAC 165:59-1-4:
Choose Type of Health Care Entity
SECTION 3: PAID CONSULTANTS
3.1 Did the healthcare entity use the services of a paid consultant to assist in obtaining the current service provider?
Choose Yes or No
3.2 Did you use the services of a paid consultant to assist in completing this Affidavit?
Choose Yes or No
3.3 If you answered “yes” to Questions 3.1 and/or 3.2, please provide the name of the consulting firm, contact person, postal mailing address, telephone number, and e-mail address of the paid consultant(s).
Firm:
Name: Telephone: E-mail:
Address 1:
Address 2:
City: State: Zip:
3.4 Does PUD have the healthcare entity’s permission to obtain information from the above-named paid consultant(s)?
Choose Yes or No
SECTION 4: PREVIOUS SERVICE PROVIDER(S)
Note – If you are completing this Affidavit as a result of a change in bandwidth and/or price with your current service provider, complete Section 4 using information about the bandwidth / price / etc. that was in effect immediately prior to the change(s).
4.1 Previous service provider:
4.2 Date service began:
4.3 Date service ended (See Section 10, Question 10.1, Attachment 3.):
4.4 Date disconnect of service was requested:
4.5 Date of actual disconnect of service:
4.6 Bandwidth provided:
Choose Mbps or Gbps
4.7 Monthly charge:
SECTION 5: CURRENT SERVICE PROVIDER(S)
All sections from this point forward should be answered with regard to the healthcare entity’s current service provider(s).
5.1 Name of service provider:
5.2 Date service began:
5.3 Bandwidth provided:
Choose Mbps or Gbps
5.4 Amount of monthly charge:
SECTION 6: ALTERNATIVE FUNDING SOURCES
Complete the responses in this Section for all applicable Funding Years or, if this Affidavit is for the purpose of Recertification, for the current year and prospective years.
6.1 Is the healthcare entity eligible for funding from Rural Health Care (“RHC”), the Healthcare Connect Fund (“HCF”), or any additional telecommunications program(s)?
Choose Yes or No
If the healthcare entity is not eligible for such alternative funding, proceed to Question 6.7.
6.2 Did the healthcare entity apply for federal funding through RHC, HCF, or additional telecommunications programs? If the answer is “yes,” proceed to Question 6.4.
Choose Yes or No
6.3 If the answer to Question 6.2 is “no,” provide a detailed explanation of the reason(s) the healthcare entity did not apply for alternative government funding, then proceed to Question 6.7.
6.4 If the healthcare entity applied for alternative government sources of funding, was funding approved? If “yes,” provide relevant documentation, then proceed to Section 7. (See Section 10, Question 10.1, Attachment 4.)
Choose Yes or No
6.5 If the answer to Question 6.4 is “no,” explain why funding was denied, and provide relevant documentation. (See Section 10, Question 10.1, Attachment 4.)
6.6 If the healthcare entity applied for alternative government sources of funding, but did not complete/finish the application process, explain why.
If you answered “no” to Questions 6.1, please answer the following question.
6.7 Have you verified through the USAC website, located at http://www.usac.org/rhc/telecommunications/tools/Rural/ search/search.asp, that the healthcare entity is ineligible for federal funding through the RHC, HCF, or additional telecommunications program? If “yes,” provide relevant documentation. (See Section 10, Question 10.1, Attachment 5.)
Choose Yes or No
If you answered “no” to Question 6.7, go to the USAC website listed, and provide PUD a copy, as Attachment 5 to this Affidavit, of the documentation that verifies the healthcare entity is ineligible for federal funding. (See Section 10, Question 10.1, Attachment 5.)
SECTION 7: REQUEST FOR PROPOSAL (“RFP”)
7.1 Did the healthcare entity submit FCC Form 461 or FCC Form 465?
Choose Yes or No
7.2 Did the healthcare entity post an RFP? (See Section 10, Question 10.1, Attachment 6.)
Choose Yes or No
7.3 How much bandwidth was requested in the RFP?
Choose Mbps or Gbps
7.4 If the healthcare entity selected a higher bandwidth than the minimum bandwidth requested in the FCC Form / RFP, provide a specific and detailed explanation for choosing a higher bandwidth. Your explanation should include additions made to equipment, software applications, or other justification for the chosen bandwidth.
7.5 Did the current service provider assist in creating the RFP?
Choose Yes or No
7.6 If you answered “yes” to Question 7.5, provide the individual's full name, postal mailing address, telephone number, and e-mail address.
Name: Telephone: E-mail
Address 1:
Address 2:
City: State: Zip:
7.7 Please list all benefits received within the previous three (3) years to the present date, whether or not the benefit(s) was of value, from all companies that submitted a bid to provide service(s) requested in the RFP. Benefits might include gifts, inducements, incentives, and/or promotions, which the healthcare entity, or any decision-maker associated with the selection of the current service provider, received in conjunction with either the RFP or the provisioning of services.
SECTION 8: BID INFORMATION
Information in this Section will be used by PUD to determine if the selected bid was the “lowest cost reasonable bid.” There may be instances in which the lowest priced bid is not the lowest cost reasonable bid. Note – if the current service provider’s Application requests funding for more than one Funding Year, please provide information for all relevant Funding Years.
8.1 How many bids were received?
8.2 Were any bids not considered?
Choose Yes or No
8.3 If you responded “yes” to Question 8.2, (1) list all bids not considered and (2) explain the reason(s) a bid(s) was not considered.
8.4 Was the lowest priced bid selected?
Choose Yes or No
8.5 If you responded “no” to Question 8.4, provide specific and detailed justification for why the lowest priced bid was not chosen. Please provide relevant documentation with this Affidavit. (See Section 10, Question 10.1, Attachment 7.).
SECTION 9: EQUIPMENT AND SERVICES
9.1 Please list telemedicine applications, hardware, etc. using the Excel file described below for Attachment 10. (See Section 10, Question 10.1, Attachment 10.)
9.2 Please list all equipment (e.g., router) provided by the healthcare entity’s current service provider as a part of the contract or agreement for services.
9.3 Please list all charges / fees for the equipment listed in your response to Question 9.2.
9.4 Please list all services / support (e.g., e-mail service, IP addresses) provided as part of your contract or agreement with the healthcare entity’s current service provider.
9.5 Please list all charges / fees for all services / support listed in your response to Question 9.4
SECTION 10: REQUIRED ATTACHMENTS
10.1 Label each attachment according to the attachment number and name in the list below. For any attachment not submitted, please provide a detailed explanation as to why it is not applicable or not available.
Attachment 1 – License / Certification
Please provide a copy of the healthcare entity's certificate or license, which identifies its qualification as a healthcare entity. (See Section 2, Question 2.1.) Choose Included, Not Applicable, or Not Available
If not submitting Attachment 1, please explain:
Attachment 2 – Verification of Not-for-profit Status
If the healthcare entity is a Not-for-profit hospital or a Not-for-profit mental health and substance abuse facility, please provide current verification of not-for-profit status (tax exempt letter from IRS). (See Section 2, Question 2.2.) Choose Included, Not Applicable, or Not Available