Apply to operate an MIH Program with ED Avoidance

Instructions for submitting a Mobile Integrated Health Care with Emergency Department Avoidance (MIH with EDA) initial or renewal application to the Department of Public Health (DPH). MIH with EDA applications must be completed by a local jurisdiction's licensed, designated, primary ambulance service only.

What you need

The MIH with EDA application form has transitioned to a new online licensing system, the Health Professions Licensing Portal.

For initial MIH with EDA applicants, you will need to create an account and follow application instructions to submit required documents. Please review the initial application instructions below prior to starting the application.

For existing MIH with EDA programs seeking renewal, you will need to create an account and link your existing license(s) to your new account. If you already have an account, you will still need to link your existing license to your account. If you have not received an email with your “Registration Pin Code”, please contact [e-mail]. Please review the detailed instructions below as significant updates have been made to the application process. 

Please note, if you wish to apply to operate either a Community EMS or a standard Mobile Integrated Health program, there are separate application instructions on their respective webpages. 

Apply for an Initial Application

Please review the Mobile Integrated Health with ED Avoidance Application Guidance form and ensure you have the following information ready for upload:

1. Proposed Program Narratives and Additional MIH with EDA Policies
2. Partner Organization Documentation
3. Gaps in Service Delivery Narratives
4. Organizational Readiness Documentation
5. Medical Oversight Documentation
6. MIH Professional and Criminal History Attestation Forms and applicable CORI Authorization Forms 
   1. 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
7. Any supplemental documentation

There will be additional information required on this application, including, but not limited to, summaries of specific areas for patient populations by proposed service, levels of care by health care provider type, areas of operation by town/city, MIH Authorized Signatory and Medical Director attestations, etc.

During the application narrative development process, please use the linked 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

Once you are ready to apply, from the Health Professions Licensing Portal licensing home page:

1. Select “Apply for a New License”
2. Locate and select “Office of Emergency Medical Services”
3. From there, select “Start Application” under “Mobile Integrated Health with Emergency Department Program Approval.” 
4. Complete application, submit payment, then submit. Please note, submission comes after payment.

Apply for a Renewal Application

Please review the detailed instructions below as significant updates have been made to the application process. 

Prior to starting the renewal application, please review the Mobile Integrated Health with ED Avoidance Application Guidance form and ensure you have updated your existing application materials. Have the following ready for upload:

1. Proposed Program Narratives
2. Partner Organization Documentation
3. Gaps in Service Delivery Narratives
4. Organizational Readiness Documentation
5. Medical Oversight Documentation
6. MIH Professional and Criminal History Attestation Forms and applicable CORI Authorization Forms 
   1. 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
7. Any supplemental documentation

There will be additional information required on this application, including, but not limited to, summaries of specific areas for patient populations by proposed service, levels of care by health care provider type, areas of operation by town/city, MIH Authorized Signatory and Medical Director attestations, etc.

If you have not yet used the new eLicensing website, you will need to create an account and link to your program approval.

• Go to the Health Professions Licensing Portal
  • Select "Create Account."
• Once you have registered or if you already have an account, log in to your account and go to "Link License to My Account." 
  • Select your license type from the "License Type" dropdown menu.
  • Enter your approval number in the "License or Registration Number" field.
  • Please ensure you enter the new MIH with EDA Approval Number (including the new prefix "MIHEDA-"). If you have not received your new MIH with EDA Approval Number via email, please contact [e-mail]. 
• You will be asked to provide a registration pin code which was emailed to the program’s primary contact. If you cannot locate the registration pin code, please contact [e-mail].  
• Once your program approval has been linked to your account, select "View Details."
  • You will see the option to start a renewal application
• Complete application, submit payment, then submit. Please note, submission comes after payment.

Fees

You may submit your fee using a credit card, debit card, or ACH payment. If you must mail a physical check or money order, please complete and attach payment to the Mobile Integrated Health Program Mail Fee Submission Form.

Initial Application - $13,000

Renewal Application - $10,000

More info

During the application narrative development process, please use the linked 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

For additional instructions, including video guides, please visit Health Professions Licensing System User Guide for information on how to get started. If you have questions about account creation, contact the eLicensing HelpDesk at 800-414-0168 or [e-mail].