BOB ANTHONY
Commissioner
PATRICE DOUGLAS
DANA MURPHY
Commissioner
Commissioner
OKLAHOMA
CORPORATION COMMISSION
P.O. BOX 52000
OKLAHOMA CITY, OKLAHOMA 73152-2000
www.occeweb.com
580 Jim Thorpe Building
Telephone: (405) 521-4114
FAX: (405) 521-3336
Brandy Wreath, Director
Public Utility Division
Oklahoma Corporation Commission - Oklahoma Universal Service Fund
Recertification Request - 2015
Date:
Pursuant to 17 O.S. § 139.109(c)(2), “Each not-for-profit hospital, county health department, city-county health
department, not-for-profit mental health and substance abuse facility as defined in Section 139.102 of this title
and federally qualified health center in this state shall, upon written request, receive, free of charge, one
telecommunications line or wireless connection sufficient for providing such telemedicine, clinical and health
consultation services as the entity's telemedicine equipment and service applications require.”
Pursuant to 17 O.S. § 139.109(E), “The Corporation Commission shall have authority to investigate and modify
or reject in whole or part a Special Universal Services request under subsection C of this section if the request
does not meet the specified criteria, if the Corporation Commission's investigation determines that the entity
has not provided sufficient justification for the requested services, or if the Corporation Commission determines
that granting the request is not in the public interest.”
Entity Type:
Not-for-profit-hospital
County Health Department
City-County Health Department
Federally Qualified Health Center (FQHC) - (Includes a tribe or tribal organization under the
Indian Self-Determination Act or by an urban Indian organization receiving funds under Title V of the
Indian Health Care Improvement Act)
ODMHSAS Operated Facility
Community Mental Health Center (OAC 450:17), Community Based Structured Crisis Center
(OAC 450:23), Community Comprehensive Addiction Recovery Center (OAC 450:24)
Department of Corrections Facility
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OCC - Oklahoma Universal Service Fund
Telemedicine Recertification 2015
This is the written recertification request of (insert name of healthcare entity)
to renew the eligibility of
telecommunications line or wireless connection sufficient for providing such Telemedicine
services as this healthcare entity is equipped to provide.
Legal Healthcare Entity Name:
Entity Operational Name/DBA:
Entity Owned By:
Entity Managed By:
Healthcare Provider Number (if applicable, as assigned by Universal Services Rural Health Care
Program):
Physical Address of Location for this application:
Contact Information:
Name:
Title:
Email:
Phone:
Telecommunications Service Provider:
Please provide the date the contract was signed with the current service provider and the length of
the contract term. Date:
Term:
Months
The bandwidth provided by the carrier is
(Mbps/Gbps) and the bandwidth being utilized
for Telemedicine is
(Mbps/Gbps) for the telecommunications line or wireless
connection. The above healthcare entity currently is using the Telemedicine line or wireless
connection for the equipment and services listed in this application.
Revised 12/2014
http://www.occeweb.com/pu/pudforms.html
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OCC - Oklahoma Universal Service Fund
Telemedicine Recertification 2015
List any use of the telemedicine line outside of the telemedicine equipment and services listed in this
recertification
request.
For
example,
security
systems,
public
Wi-Fi, voice communications, billing, scheduling, and third-party agencies within the facility.
Pursuant to OAC 165:59-7-1, “recipients of Special Universal Services shall make every reasonable effort to
obtain funding from another state/and/or federal fund designated to support special universal
service…recipients shall provide the Commission with information regarding the recipient’s request for funding
from government sources designed to support the provisioning of telemedicine. Failure to provide such
documentation regarding telemedicine may result in the Commission denying the request for telemedicine
funding from the OUSF.”
Is the entity eligible for the Federal Universal Services Rural Healthcare Program?
(Telecommunications Program or Healthcare Connect Fund)
Yes
No
If yes, has the entity sought or is in the process of seeking funding from the Federal Universal
Services Rural Health Care Program?
Yes
No
Healthcare Provider, please provide the following required documents as attachments to complete
this recertification request:
A. Please provide an explanation as to whether or not, the healthcare entity used competitive
bidding in selecting the current provider.
If there was no competitive bidding process, please provide justification for not using a
competitive bidding process.
B. Attach a network diagram of the facility or facilities. Please indicate circuit numbers (if
available) and bandwidth.
C. Detailed list of Telemedicine equipment and software applications used to provide
telemedicine services from this facility. Please include information on how your facility stores
any imaging and backs up EMR/EHR data (if applicable).
Revised 12/2014
http://www.occeweb.com/pu/pudforms.html
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OCC - Oklahoma Universal Service Fund
Telemedicine Recertification 2015
D. List of FCC Forms or other documentation demonstrating that Universal Services Rural Health
Care Funding or other federal or state funding has been sought or is being sought for the
services supported by OUSF. Acceptable forms include FCC Forms 465, 466, or 467 for the
telecommunications program or FCC Forms 461, 462 or 463 for the Health Care Connect
Fund (HCF). – Copies of Form 467 (telecommunications) or Form 463 (HCF) will need to be
forwarded to PUD upon confirmation of services and request of payment to the service
provider.
E. Please include a copy of the service contract with your current carrier and the most recent two
months invoices
F. Bandwidth Utilization Study – PUD suggests a minimum of 3 months, if available
G. Please provide all certificates/licenses indicating entity qualifies as a not-for-profit hospital,
county health department, city-county health department, federally qualified health center
(FQHC), Community Mental Health Center (OAC 450:17), Community Based Structured Crisis
Center, Community (OAC 450:23), or (OAC 450:24) Comprehensive Addiction Recovery
Center.
H. For hospitals, Community Mental Health Center (OAC 450:17), Community Based Structured
Crisis Center (OAC 450:23), and Community Comprehensive Addiction Recovery Centers
(OAC 450:24) the following documentation should be provided: Public Trust Document, State
or County Authority Documentation, or IRS Tax exemption documentation. State/Excise Tax
exemption is NOT sufficient.
I understand that the telecommunications line or wireless connection is for the exclusive use of this
healthcare entity and that under no circumstances shall the services be resold, repackaged or shared
with any other entity. This includes outside contracted agencies housed/doing business in this facility.
Initial
I hereby authorize the carrier to provide to the Oklahoma Corporation Commission our invoices,
related contracts, and other supporting documentation for services eligible to be reimbursed from the
Oklahoma Universal Service Fund. I understand the purpose of this release of records is to allow the
Corporation Commission to continue to review eligibility for OUSF support.
Initial
Revised 12/2014
http://www.occeweb.com/pu/pudforms.html
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OCC - Oklahoma Universal Service Fund
Telemedicine Recertification 2015
Please note: This application is NOT complete without ALL applicable required attachments
submitted by February 1, 2015.
The undersigned certifies that he/she has the authority to make this request for recertification on
behalf of the above named Healthcare Entity.
Signature of Healthcare Entity Administrator
Administrator
Printed Name of Healthcare Entity
Address
Telephone Number
City, State Zip
Email Address
State of Oklahoma
County of
Subscribed and sworn to before me this
day of
, 20
Notary Public
(seal)
My commission expires
.
Revised 12/2014
http://www.occeweb.com/pu/pudforms.html