EmailMe Form - Application For MIH Accreditation

Application For MIH Accreditation

1. Complete this initial application.

2. Return to the CAMTS office the $1000.00 application fee.

3. You will then receive the Program Information Form (PIF) by email.

4. You have up to 1 year to complete the PIF.

5. Submit the PIF and the attachments requested following the instructions on the PIF.

6. Your site visit will be scheduled within 4 – 6 weeks of receiving the PIF.

7. An accreditation decision will be made at the next Board of Directors meeting. The Board meets three times a year.

PIF DUE DATES -
For the Spring Meeting - PIF due December 15
For the Summer Meeting - PIF due March 15
For the Fall Meeting - PIF due June 15

Name of Mobile Integrated Healthcare Program
Mailing Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Web Site
Name and Address of Sponsoring Agency
Business Phone
### - ### - ####
Principle Contact
First Last
Title
Email
Phone
### - ### - ####
Meeting Goal
Spring
Summer
Fall
How will you pay the application fee
Check
Credit Card
(PIF will be emailed once we receive check)
(There will be a processing fee added if paying with card card and PIF will be emailed shortly)
Types of Service (Check all that apply to your service)
Community Services based (Health Consortiums, etc.)
For profit company based
Hospital based
Independent Private Non-profit based
Physician Practice based
Public Health based (local, regional, state Health Departments, etc.)
Public Safety based (Police, Fire, EMS)
Total number of Part-time Employees
Total number of Full Employees
Total number of current patient/clients
Total number of patient/client encounters in most recent fiscal year
Please upload a one page description of your program. *
Privacy Policy *
Click here to state that you have read and agree to our Privacy Policy
Go here to view - https://www.camts.org/privacy/
Office use only -
Date received:
Program Number:
Entered into database:
Payment received:
Emailed PIF:
Sent Packet:

Office use only -