MHIP Speaker Request

If you'd like to have a representative of MHIP speak or present information at your event, please complete the form below. Your information will be sent directly to our staff and one of our representatives will contact you as soon as possible.

If you'd prefer to complete this form offline, you can download our Speaker Request Form as a PDF. Our Fax number and Mailing address are included on the form.

Speaker Request Form - Requires Adobe Acrobat Reader.


Organization Name is required.

Event Information


Event Name is required.


Event Date(s) required.


Event Time(s) required.


Address required.


Purpose required.


Time required.


Length required.


Topic required.

Contact Information


Contact name required.


Phone required.
Incorrect format.


Email required.

Miscellaneous Information

Email is not necessarily secure or confidential. Send only the information that is necessary for MHIP to respond to your question or process your request.

* - required field  
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Apply for MHIP Coverage

Applications accepted until 11-15-13.

It's easy to apply for MHIP coverage. We've put together a simple checklist to help you get all your information in order.

Go to the Apply Now Checklist Page for information and helpful links.

Download the MHIP Application.

Need help with your application?
Call us at 800-821-2231.

Appeals and Grievances

Appeals and Grievances should be filed in accordance with State Pool Certificate of Coverage (page 45).

State Pool Certificate of Coverage