Harrison County Community Hospital – HCCH Medical Clinic — Rural Health Care posted service request (Telecom)

FCC Form 465 General Information HCP: 26030 - Harrison County Community Hospital – HCCH Medical Clinic FCC Registration Number: 0014989149 Address: 3202 MILLER ST , BETHANY, MO 64424-2713 Application Nickname: FY26 Funding Year: 2026 Application Number: RHC46500002561 Funding Priority: Priority 1 Main Contact Who is the main contact for this request? tertiary - Jennifer Hibbs First Name: Jennifer Middle Initial (Optional): Last Name: Hibbs Organization Name: Harrison County Community Hospital – HCCH Medical Clinic Title: Consultant Phone: 8165078970 Extension (Optional): Fax (Optional): Email: jenhibbs@icevolutionllc.com Address Line 1: 6100 NW 78th Street Address Line 2: City: Kansas City State: MO Zip Code: 64151 Requested Services Type of Services Description for Other Min Download Speed Max Download Speed Min Upload Speed Max Upload Speed Speed Unit Number of Lines Allow Bids for Similar Services Voice 21 Yes Dates and Timing What is the HCP's desired service contract length? Equal to 3 Year(s) Will the HCP consider bids with contract extension language? Yes Page 1 Will the HCP consider bids for month-to-month agreements? Yes What is the HCP's desired time to publicly post this Request for Services? 28 Day(s) What is the HCP's expected bid evaluation period after the public posting? 1 Day(s) Bid Evaluation Criteria Description Evaluation Weight (%) Minimum Requirement Price 75 Other PAST PERFORMANCE 25 PAST EXPERIENCE OR 2 REFER ENCES Does the HCP have any disqualifying factors that will remove bids or bidders from consideration? No RFP & Summary Do state, Tribal, or local procurement rules require the HCP to include an RFP with this request for services application? No Will the HCP be including an RFP with this application? No Please provide a summary of the HCP's requested services. If an RFP is attached above, summarize that document: THE HCP IS SEEKING VOICE SERVICE FOR 21 PHONE LINES. Page 2 Additional Documentation Description Document Uploaded On Declaration of Assistance Have any consultants, service providers, or any other outside experts, whether paid or unpaid, aid in the preparation of the FCC Form 465, RFP, bid evaluation or network plan? Yes Name Title Employer Nature of Relationship State Email Telephone Jennifer Hibbs Consultant Integrity Consultin g Evolution, LLC Consultant MO jenhibbs@icevolutionllc .com (816) 507-8 970 Page 3 Certifications ✓ I certify under penalty of perjury that I am authorized to submit this request on behalf of the applicant. ✓ I certify under penalty of perjury that the applicant has complied with all applicable state, Tribal, or local procurement rules. ✓ I certify under penalty of perjury that all requested RHC Program support will be used solely for purposes reasonably related to the provision of health care service or instruction that the applicant is legally authorized to provide under the law of the state in which the services are provided. ✓ I certify under penalty of perjury that the applicant seeking supported services is a nonprofit or public entity that falls within one of the categories set forth in the definition of health care provider listed in 47 CFR §54.600, or the applicant seeking supported services has received conditional approval of eligibility pursuant to 47 CFR § 54.601(c) and expects to qualify as a nonprofit or public entity health care provider that falls within one of the categories set forth in the definition of health care provider listed in 47 CFR §54.600, before the end of the funding year for which the supported services are requested. ✓ I certify under penalty of perjury that the applicant seeking supported services is physically located in a rural area as defined in 47 CFR § 54.600 or is a member of a consortium that satisfies the majority-rural composition requirements set forth in 47 CFR § 54.607, or the applicant seeking supported services has received conditional approval of eligibility pursuant to 47 CFR § 54.601(c), and the applicant (i) expects to be physically located in a rural area as defined in 47 CFR § 54.600 before the end of the funding year for which the supported services are requested, or (ii) plans to be a member of a consortium which satisfies the majority-rural composition requirements set forth in 47 CFR § 54.607 before the end of the funding year for which the supported services are requested. ✓ If applying for conditional approval of eligibility, I certify under penalty of perjury that the applicant seeking supported services has provided a written notification to potential bidders that the entity’s eligibility is conditional and specify the estimated eligibility date pursuant to § 54.601 (c)(2). ✓ I certify under penalty of perjury that the applicant has reviewed and will comply with all applicable RHC Program requirements. ✓ I certify under penalty of perjury that I have examined this request and all attachments, and to the best of my knowledge, information, and belief, all statements contained herein and in any attachments are true. ✓ I certify under penalty of perjury that the supported services will not be sold, resold, or transferred in consideration for money or any other thing of value. ✓ I certify under penalty of perjury that the applicant satisfies all of the requirements under section 254 of the Communications Act and applicable Commission rules. ✓ I understand that all documentation associated with this request must be retained for a period of at least five years pursuant to 47 CFR § 54.631, or as otherwise prescribed by the Commission's rules. Signature Certifier’s Full Name: Jennifer Hibbs Digital Signature: Jennifer Hibbs Date: 02/24/2026 Page 4