Contacts
Mobile Integrated Health Care Program
The Details
What you need
The MIH application form must be completed by health care entities for proposed services in Massachusetts.
During the application process, please use the guidance information and documentation to help craft your program and application:
- MIH and Community EMS applicant and program guidance
- Guidance for Preparing Gap in Service Delivery Narrative
- MIH and Community EMS Regulations
Please note, if you wish to apply to operate either a Community EMS or Mobile Integrated Health with Emergency Department Avoidance (MIH with EDA) program, there are separate applications on their respective webpages.
Application Requirements
A complete MIH application includes:
- Completed MIH Application Form (PDF) | (DOCX), including all required attachments, descriptions, and narratives
- MIH Compliance and Capacity Form (PDF) | (DOCX) with CORI Form (PDF) l (DOCX), if applicable
- Please note that forms must be notarized based on a government-issued photo ID and include the signature of a Notary Public with the stamp or seal on page 3
- MIH Program $1,000 application fee submitted with the MIH Program Application Remittance Form (PDF) | (DOCX)
Next Steps
Application Review
Once the Department has completed the review process, you will receive a Conditions letters indicating the program is approved contingent on receiving payment for the $5,000 MIH Program Registration Fee with the MIH Program Registration Remittance Form (PDF) | (DOCX). You will submit the registration payment and form after you receive your Conditions letter.
Once the registration fee and remittance form are received, you will be issued your official Certificate of Approval which will be valid for 2 years.
Fees
Please note: Applicants who also apply to operate an MIH with ED Avoidance Program must submit a separate MIH with ED Avoidance application fee.
| Name | Fee | Unit |
|---|---|---|
| MIH Program application fee | $1,000 | per application |
| MIH Program registration fee | $5,000 | per Certificate of Approval |
How to apply
- Application
- Please fax the complete application form and all required attachments to (617) 887-8751.
- DPH will notify each applicant by email when the application form and all attachments have been received.
- Payment
- Please mail a check or money order made out to the “COMMONWEALTH OF MASSACHUSETTS” with a completed MIH Program Application Fee Remittance Form to:
- Massachusetts Department of Public Health
Office of Emergency Medical Services
Mobile Integrated Health Care Program
67 Forest Street, Marlborough, MA 0175
- Massachusetts Department of Public Health
- MIH Program Registration Remittance Form (PDF) | (DOCX)
- Please mail a check or money order made out to the “COMMONWEALTH OF MASSACHUSETTS” with a completed MIH Program Application Fee Remittance Form to:
- Application
- Please mail the complete application form and all required attachments to the address below under payment.
- DPH will notify each applicant by email when the application form and all attachments have been received.
- Payment
- Please mail a check or money order ($1,000 application fee) made out to the “COMMONWEALTH OF MASSACHUSETTS” with a completed MIH Program Application Fee Remittance Form to:
- Massachusetts Department of Public Health
Office of Emergency Medical Services
Mobile Integrated Health Care Program
67 Forest Street
Marlborough, MA 0175
- Massachusetts Department of Public Health
- MIH Program Registration Remittance Form (PDF) | (DOCX)
- Please mail a check or money order ($1,000 application fee) made out to the “COMMONWEALTH OF MASSACHUSETTS” with a completed MIH Program Application Fee Remittance Form to: