Membership Application

Download Our Printer-Friendly Membership Application

Please print and complete the Member Application and return it to:

SCBCH
800 E. Washington St, Suite K
Greenville, SC 29601

Or please fill out our online application:

Download Form

New Member Information
Primary Contact Name*
First Last
Organization Name*
Primary Contact Title
Mailing Address*
Street Address Address Line 2 City State ZIP Code
Is your street address the same as your mailing address?*
- Yes
- No
Street Address*
Street Address Address Line 2 City State ZIP Code
Phone Number*
Email Address*
Fax Number
Are you representing a municipality or government agency?*
- Yes
- No
Are you representing an employer, hopsital, physicians group, pharmaceutical manufacturer or broker/consultants?*
- Yes
- No
Are you representing a health plan or third party administrator (TPAs)?*
- Yes
- No
Employee Information
Number of Employees in South Carolina*
Number of Retirees in South Carolina*
Number of Covered Lives in South Carolina*
Number of Employees Out-of-State*
Number of Retirees Out-of-State*
Number of Covered Lives Out-of-State*
Broker Information
Name*
First Last
Organization*
Phone*
Health Plan Information
Plan Name*
PBM Name (If Different)
South Carolina Business Coalition on Health Goals

Please thoroughly read the South Carolina Business Coalition on Health (SCBCH) goals below and the Confidentiality Statement before signing your Membership Application. Your signature indicates your commitment to support the goals and honor the confidentiality of the SCBCH.
- Improved healthcare quality and efficiency
- Healthier people
- Greater consumer responsibility
- Improved economic competitiveness
Representative Name*
First Last
Date of Application*
Respresentative's Digital Signature (Please Retype Name)*
First Last
Confidentiality Agreement

The party below agrees that any information concerning the SCBCH or information concerning it’s member organizations, it’s contracts, or any other aspect of it’s business, (which is not public knowledge), shall be held in strict confidence and not used by the party, or disclosed by the party to any person or organization other than the party’s employees/agents, without the prior written consent of the SCBCH Board Chair.
Representative Name*
First Last
Date of Application*
Respresentative's Digital Signature (Please Retype Name)*
First Last
Permission to Link on www.scbch.org

I, ______________, as a representative of ______________ (organization) certify and grant permissionto the South Carolina Business Coalition on Health for the use of our name and web site address as a hyperlink on the SCBCH web site. This link is for information purposes only, and not for advertisement or profitable marketing.
Website URL
Representative Name
First Last
Date of Application
Respresentative's Digital Signature (Please Retype Name)
First Last

Membership Application

Or please fill out our online application:

New Member Information

Employee Information

Broker Information

Health Plan Information

South Carolina Business Coalition on Health Goals

Confidentiality Agreement

Permission to Link on www.scbch.org