New Listing Request (US-based telehealth sites)

Tell us about your telehealth service

Please provide details about your telehealth service so that we can consider including it in the Plan C Guide. You can save your work and return to the form later by clicking "Save" at the bottom.
Name of your service*
Name of point person
This will not be shared publicly. This is who we will contact about your listing.
Email address of point person*
This will not be shared publicly
Phone number of point person
This will not be shared publiclyFormat: (000) 000-0000.
Your URL*
Please provide the most-direct link to your telehealth/pills by mailservice. This could be a link to where to schedule an telehealth appointment, or whereto access a form to request pills by mail.
Places where you offer telehealth abortion service*
You can select multiple states by holding down the Ctrl or Cmd keys.
Pricing & financial assistance
What is the price of telehealth medication abortion service as listed on your website? (You will have an opportunity below to provide more details about your pricing structure.)*
Accepts some insuranceAccepts medicaidDiscounts available (sliding scale pricing)This is a free serviceNo financial aid availableOther
In which states can you take private insurance at this time?
You can select multiple states by holding down the Ctrl or Cmd keys.
In which states can you take Medicaid at this time?
You can select multiple states by holding down the Ctrl or Cmd keys.
Patient asks for a discount during intake and pricing is agreed upon through email correspondence.We require documentation of need.Patient can interact with the intake form to instantly set their own pricing at the time of their online consultation.Other
If you provide sliding scale pricing, please indicate the minimum price:
If you provide sliding scale pricing, please indicate the maximum price:
Is there anything else we should know about the price of your service (e.g., sliding scale options, price variation by state, price differences by modality)?
Delivery
How long does it typically take for pills to be delivered, once the patient has completed their intake form?*
Clinic pickup availablePharmacy pickup available
Please provide more details about pharmacies and/or clinic locations where in-person pickup is available.
Is there anything else we should know about delivery options? If you offer in person pick-up, please indicate the city/state in which pick up is possible.
Ages served
All ages12+13+14+15+16+17+18+Other
Do the ages you serve vary by state? Are there other age-related specifics? Please explain:
Gestational age
6 weeks or less7 weeks or less8 weeks or less9 weeks or less10 weeks or less11 weeks or less12 weeks or less13 weeks or less14 weeks or lessOther
Do the gestational ages you serve vary by state? Please explain:
Services offered
Pills in advanceMissed period pills (to be listed as a Missed Period Pill provider, information about missed period pills must be clearly visible on your website; to learn more about missed period pills visit missedperiodpills.org)For confirmed pregnancies onlyMedications for pain and nausea included (no extra cost)Medications for pain and nausea available (with additional fee)8 or more misoprostol included
How many misoprostol do you include?
What is the price of pills in advance (if different from pricing/discount eligibility of medication abortion service)?
What is the price of period pills (if different from pricing/discount eligibility of medication abortion service)?
Do the services you offer vary by state? Please explain:
YesNo
Medication provided
Please explain how many pills of each medication you send for specific gestational ages below:
Online intake by form (asynchronous telehealth care)Video visit required (synchronous telehealth care)Video visit available on request, but not requiredCommunicate by textCommunicate by emailCommunicate by phoneCommunicate by secure portalNo ID required
Patient/provider interaction
We give patients a phone number so they can reach us if they have questionsWe give patients an email so they can reach us if they have questionsWe give patients information about follow up resources that are operated by other entities (e.g. Miscarriage and Abortion Hotline)We have a patient support chat bot/app that is available 24/7Other
Available 24/7Available limited hoursOther
Do any of these options vary by state? Please explain:
Provider identity
BIPOC-ledLGBTQ+-ledWoman-ledVeteran-ledIndigenous-ledDisabled-ledOther
Languages
Select all languages that you offer:
You can select multiple states by holding down the Ctrl or Cmd keys.
Description of service
Write a brief, 2-3 sentence description of your service.*

This will be displayed on your listing. Please avoid duplicating details that are present in the form fields above. Need ideas? Click on any listing at plancpills.org0/800
If you offer services in Spanish, you can provide a preferred translation of your description here:

0/1000
Additional information
Is there anything else we should know about your service?
Please avoid duplicating details that are present in other form fields.
Do you have any questions for us?
After submitting this form you will receive an email with a personalized link to your submission. Please save this link to make changes to your listing in the future.

We will review your submission and contact you if we have questions or need additional information.

Thank you.
Should be Empty:

All US states and territories
All US states (no territories)
Military Addresses
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Mexico
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington D.C.
West Virginia
Wisconsin
Wyoming

All US states and territories
All US states (no territories)
No US states or territories
Military Addresses
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Mexico
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington D.C.
West Virginia
Wisconsin
Wyoming

All US states and territories
All US states (no territories)
No US states or territories
Military Addresses
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Mexico
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington D.C.
West Virginia
Wisconsin
Wyoming

English
Spanish
Afrikaans
Arabic
Dutch
Farsi
French
German
Hindi
Hmong-Mien
Indonesian
Italian
Japanese
Korean
Lithuanian
Magyar
Malay
Polish
Portuguese
Punjabi
Russian
Sinhalese
Slovak
Swedish
Tamil
Thai
Tagalog
Turkish
Ukrainian
Xhosa

Tell us about your telehealth service

Pricing & financial assistance

Delivery

Ages served

Gestational age

Services offered

Medication provided

Patient/provider interaction

Provider identity

Languages

Description of service

Additional information