Get Added To Our Database Blank Form (#3)Organization NameAddressAddress Line 1Address Line 2CityStateZip CodeCountrySelect CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelauBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDemocratic Republic of the Congo (Kinshasa)DenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRepublic of the Congo (Brazzaville)ReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabwePhone/MobileWebsiteLocation Bethune Camden Cassatt Elgin Lugoff Virtual/TelehealthAccepted Method of Payment Free For Those Who Qualify Medicaid Medicare Sliding-Fee Scale Self-Pay Tri-Care Private Insurance Not ApplicableCategory General Health- Organizations that cater to the body's physical health (general practitioners, dentist, pharmacists, etc.) Behavioral Health- Organizations that cater to a person's emotional well-being (psychological, substance use, mental health, etc.) Community Health- Organizations that cater to the improvement and well-being of individuals and communities (food, transportation, other social services). General Health Acupuncture Cardiology Dental Dermatology Dialysis Family Practice Gastroenterologist Hospice Imaging Center Infectious Disease Internal Medicine Nephrologist Nursing Home OB/GYN Orthopedics Pain Management Pediatric Care Pharmacy Physical Therapy Podiatry Respiratory Care Sleep Studies Urgent Care Urology Vision Other (Please specify all that apply, with multiple entries separated by a comma.)General Other (Please specify all that apply, with multiple entries separated by a comma.)Behavioral Health Types Counseling Domestic Violence Psychiatry Rehabilitation Substance Use Services Other (Please specify all that apply, with multiple entries separated by a comma.)Behavioral Other (Please specify all that apply, with multiple entries separated by a comma.)Community Health Types Clothing Assistance Continuing Education Disaster Services and Emergency Preparedness Emergency Response Exercise Financial Counseling/Education Fire Protection Services Food Assistance Law Enforcement Shelter Support Groups Transitional Housing Vocational Rehabilitation Other (Please specify all that apply, with multiple entries separated by comma.)Community Other (Please specify all that apply, with multiple entries separated by a comma.)Services Acute Care Career Development Case Management Chronic Care Clothing Court Advocacy CT Scans Dialysis Drugs & Alcohol Financial Assistance Flu Shots Food Distribution Food Stamps/SNAP Health Coaching Home Visiting Independent Living Injury Prevention Laboratory Services Mammography Massage Therapy Medication Counseling Minor Wounds and Illnesses Occupational Therapy On-Site Pharmacy Pap Smears Pediatric Care Physicals Prescription Refills Prosthetics Rehabilitation Services (Drugs & Alcohol) Respite Care Screenings Shelter Short-Term Stays Sleep Lab Smoking Cessation Spanish Interpretation Speech Therapy Sports/Work-Related Injuries Transportation Services Ultrasound Utility Payment Assistance Vaccinations/Immunizations Wellness Checks Writes Rx X-Ray Other (Please specify all that apply, with multiple entries separated by a comma.)Services Other InformationPoint of Contact for Future Updates/InquiriesPoint of Contact Phone NumberPoint of Contact EmailPlease let us know if you have any thoughts, ideas, or questions about this process.Submit Form
