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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 ED Avoidance application form must be completed by a health care entity that is partnering with the applicable local jurisdiction(s)’ designated primary ambulance service(s).
- 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: If applying to operate an MIH with ED Avoidance program, the applicant must either have a Certificate of Approval for an approved MIH Program OR submit an MIH application, with all required attachments, responses, and application fee, at the same time as submitting the MIH with ED Avoidance application.
Application Requirements
A complete MIH with ED Avoidance application includes:
- Completed Application Form (PDF) | (DOCX), including all required attachments, descriptions, and narratives
- Either (1) completed MIH Application (PDF) | (DOCX) or (2) Certificate of Approval for an approved MIH Program
- MIH with ED Avoidance Program application fee and Registration Remittance Form (PDF) | (DOCX)
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 | $2,000 | per application |
| MIH with ED Avoidance Program registration fee | $5,000 | per Certificate of Approval |
How to apply Apply to operate an MIH Program with ED Avoidance
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 with ED Avoidance
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 with ED Avoidance program must submit payment for the $40,000 MIH with ED Avoidance Program Registration Fee with the MIH with ED Avoidance Program Registration Fee Remittance Form.
- Once the registration fee is received, DPH will issue a Certificate of Approval to operate an MIH with ED Avoidance Program. Certificates of Approval are valid for 2 years.