Contacts
Mobile Integrated Health Care Program
The Details of Apply to operate an MIH Program with ED Avoidance
What you need for Apply to operate an MIH Program with ED Avoidance
The MIH with EDA 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 a standard Mobile Integrated Health program, there are separate applications on their respective webpages.
Application Requirements
A completed application includes:
- Completed MIH with EDA Application Form (PDF) | (DOCX), including all required attachments, descriptions, and narratives
- Instructions to create an electronic signature
- MIH Compliance and Capacity Form (PDF) l (DOCX) with CORI Form (PDF) | (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 with EDA Program $3,000 application fee submitted with the MIH with EDA 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 $10,000 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 for Apply to operate an MIH Program with ED Avoidance
Please note: An MIH with ED Avoidance program applicant is required to submit a completed MIH application or Certificate of Approval for an MIH program with their application. The applicant is responsible for program application fees ($3,000 in total) and registration fees ($10,000 in total) for each of the two programs.
| Name | Fee | Unit |
|---|---|---|
| MIH with ED Avoidance Program application fee | $3,000 | per application |
| MIH with ED Avoidance Program registration fee | $10,000 | per Certificate of Approval |
How to apply Apply to operate an MIH Program with ED Avoidance
- 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
- Please mail a check or money order made out to the “COMMONWEALTH OF MASSACHUSETTS” with a completed MIH Program Application Fee Remittance Form to:
- MIH with EDA Program Application Remittance Form (PDF) | (DOCX)
- 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 ($3,000 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 with EDA Program Application Remittance Form (PDF) | (DOCX)
- Please mail a check or money order ($3,000 application fee) made out to the “COMMONWEALTH OF MASSACHUSETTS” with a completed MIH Program Application Fee Remittance Form to: