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Mobile Integrated Health Care Program
The Details of Apply to operate an MIH Program
What you need for Apply to operate an MIH Program
The MIH application form must be completed by health care entities for proposed services in Massachusetts.
- The application is posted as a fillable PDF. You will need to have either Adobe Acrobat or Adobe Reader installed on your computer to complete the application form.
- When you open the application, please download and save it to your computer before filling it out. If you fill out the application in your Internet browser without saving, all changes will be lost once the browser window is closed.
- The application allows applicants to use an electronic signature. Please note that handwritten documents and attachments will not be accepted. If you need assistance setting up your electronic signature, please see the Instructions to create an electronic signature.
Please note: Applicants who also apply to operate an MIH Program with ED Avoidance must submit a separate MIH with ED Avoidance application, with all required attachments, responses, and application fee.
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 with CORI Form, 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 application fee: $1,000
Fees for Apply to operate an MIH Program
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 Apply to operate an MIH Program
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.
Next steps for Apply to operate an MIH Program
Application Review
- Once a completed application form and the application fee are received, DPH will review the information and will contact the applicant if clarifications or additional information for the submitted application materials are needed.
- Upon receiving application approval from DPH, the MIH program must submit payment for the $5,000 MIH Program Registration Fee with the MIH Program Registration Remittance Form (PDF) | (DOCX)
- Once the registration fee is received, DPH will issue a Certificate of Approval to operate an MIH Program. Certificates of Approval are valid for 2 years.
Downloads for Apply to operate an MIH Program
Open DOCX file, 680.67 KB,
Instructions to create an electronic signature
(English, DOCX 680.67 KB)
Open PDF file, 222.9 KB,
MIH Application Form
(English, PDF 222.9 KB)
Open DOCX file, 164.23 KB,
MIH Application Form
(English, DOCX 164.23 KB)
Open PDF file, 303.03 KB,
Compliance and Capacity Form
(English, PDF 303.03 KB)
Open DOC file, 125 KB,
Compliance and Capacity Form
(English, DOC 125 KB)
Open PDF file, 338.19 KB,
CORI Form
(English, PDF 338.19 KB)
Open DOCX file, 48.86 KB,
Accessible Application
(English, DOCX 48.86 KB)
Open PDF file, 209.72 KB,
Application Remittance Form
(English, PDF 209.72 KB)
Open DOCX file, 36.53 KB,
Application Remittance Form
(English, DOCX 36.53 KB)
Open DOCX file, 36.5 KB,
Registration Remittance Form
(English, DOCX 36.5 KB)
Open PDF file, 208.38 KB,
Registration Remittance Form
(English, PDF 208.38 KB)