Rural Health Care

Forms

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. All HCF Program forms and supporting documentation must be submitted by filing online through My Portal.

FCC Form 460

File Online

Eligibility and Registration Form

Community Mental Health Center Checklist

FCC Form 461

File Online

Request for Services Form

FCC Form 462

File Online

Funding Request Form

FCC Form 463

File Online

Invoice and Request for Disbursement Form

Click here for 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 via email or at (800) 453-1546 to make alternative arrangements.