Register with the Directory of Emergency Contraception Providers

Educating and empowering women in South Carolina by increasing awareness of and access to emergency birth control

ATTENTION HEALTH CARE PROVIDERS AND PHARMACISTS

Also available in [PDF] format.

Did you know that one-half of the unintended pregnancies in South Carolina could be prevented?

Each day, thousands of women under the age of 25 in South Carolina face the possibility of a pregnancy they did not intend and may not want – because their regular method of contraception failed, they were raped or sexually assaulted, or they didn’t use a method of protection.

Emergency birth control pills, also called emergency contraception or the morning after pill, are a safe and effective method of preventing pregnancy if taken up to 72 hours (three days) after unprotected sex. If emergency contraception was widely available, it could prevent up to 50 percent of unintended pregnancies in South Carolina.

But emergency contraception is NOT widely available to young women in South Carolina.

Many young women (60 percent!) don’t know about emergency birth control pills.
Some doctors won’t prescribe emergency contraception without parental consent, even though the law does not require parental consent for women over the age of sixteen.*
Many pharmacies do not regularly stock the only dedicated brand of emergency contraception, Plan B^®.
In August 2006, the FDA approved nonprescription sales of emergency birth control pills for young women ages 18 and older. Pharmacies now provide this medication without prescription.
Young women under age 18 will continue to need a prescription to obtain emergency birth control.

How can pharmacists and health care providers help? By making EC available and registering with the national EC hotline and Web site.

Princeton University and the Association of Reproductive Health Professionals (ARHP) maintain a national EC hotline and Web site, not-2-late.com. Young women can use it to find a provider of emergency contraception in their geographical area. By registering with the directory of EC providers you will join a broad network of providers in a variety of health care settings, including community health clinics, family planning clinics, urgent care centers, hospital emergency rooms, college health centers, and private practices.

How will young women find out about the registry?

In 2006-08, the South Carolina Emergency Contraception Initiative will be conducting a broad public awareness campaign in Charleston, Columbia, Greenville, and Spartanburg to educate young women ages 16-24 about emergency birth control pills and inform them about where they may obtain the medication. Young women will learn about the hotline and Web site through the public education campaign.

Be a part of the solution! Complete this registration form and join the nationwide network of EC providers. Young women in South Carolina need your help – sign up today!

*For young women under 16, the health care provider may provide emergency contraception without parental consent where they determine that it is appropriate for the minor.

________________________________________________________________________________________

SIGN-UP FORM FOR THE DIRECTORY OF PROVIDERS OF EMERGENCY CONTRACEPTION
Emergency Contraception Hotline (1.888.NOT.2.LATE)
Emergency Contraception Web site (www.not-2-late.com)

Before completing this form, please make sure that you are not already listed in the Directory by calling the Hotline or browsing the Web site. If you are not already listed, complete, sign, and return this form. If you are already listed but your information has changed or you want to be removed from the Directory, please mail us a written request. We will send a provider information verification form annually for your review. Thank you for your participation.

Please notify everyone on your staff (especially those who answer the telephone) that you offer emergency contraception and that you will be listed in the Directory.

Please note that the Web site and Hotline will normally list only the clinic/office/pharmacy name, city, state, telephone number, Web site address, and whether your services are limited to qualified clients (e.g. a student health service that serves only enrolled students). We ask for additional information on this form for our records, so please complete the entire form.

Name of clinic/office/pharmacy:___________________________________________________

(Check where to send verification form: Clinic:  Administrative office noted at bottom of form: )

Administrative contact:____________________________ Email:________________________

Mailing address:________________________________________________________________

City:___________________________ State:_____________ Zip Code:___________________

Telephone: _(_____)______________ (toll numbers only—no 800 numbers or extensions can be listed)

Centralized Appointment Number:(____)______________ Toll Free Number: _(____)________________

Fax: _(____)__________________ Web site address: _____________________________________

If—and only if—the clinic/office/pharmacy name and telephone number are insufficient to get a client to an appropriate person, indicate below what additional information would be required (e.g. name of clinician):

________________________________________________________

If your practice sees exclusively only certain types of patients (e.g. students, teens, established clients), please indicate by checking the appropriate box so that we can put this information on both the Web site and Hotline.

 College student health service		 Indian Health Service
 Military health service		 Health Maintenance Organization
 Women aged ______ and younger		 Established clients
 Other ______________________

Your signature below indicates that you have authority to include your office/clinic/pharmacy in the directory of providers of emergency contraception (EC), that your office/clinic/pharmacy has staff with authority to prescribe medication, that your office/clinic/pharmacy offers EC, and that we have your permission to verify the information you provide at our discretion.

Signature: ___________________________________________ Date:______________________

For administrative purposes, if you are part of a larger medical group or affiliate that has one central administrative office (for example, a Planned Parenthood clinic under an affiliate or a private practice with multiple offices) please provide the information below.

Administrative contact name: ________________________________________________

Name of group:____________________________________________________________

Mailing Address:____________________________________________________________

City:_________________________ State: __________Zip Code: ___________________

Telephone: _(_____)______________Fax: _(_____)______________

Email:____________________________________

RETURN THE COMPLETED FORM TO: Emergency Contraception Hotline, Office of Population Research, Wallace Hall, Princeton University, Princeton, NJ 08544. (Fax: 609-258-1039)