PHC Intake Form: A Guide for Retailers

Interested in joining the ProHealth Connect network and looking for help on how to get started? You’re in the right place. This article will be the first in a series to help retailers through the PHC intake process, starting with completing the PHC intake form. 

Important: Special characters such as &, #, or * are not allowed in any field.

Entering your Business Information 

This section defines important information about your business. Be sure to match what is on your official business documentation including tax records, bank statements, or licenses issued by your state or local government. 

Required fields: 

- Company Name — The full legal name of your business. 

- DBA Name — “Doing Business As” name. If your business uses a different name from the full legal name of your business, add it here; if not, please enter your Company Name again. Do not leave this field blank. 

 - EIN (Employer Identification Number) — Your nine-digit (9) EIN number, sometimes called a tax ID or business ID. It follows the following format:

##-#######

Important: When entering your EIN into the form, please do not include the dash; your EIN number should look like this

######### 

Add Owner and Contact Details

This section allows PHC to contact you for verification or updates. 

• Owner Name — The full name of the person legally responsible for the business. It could be the actual owner of the business or an authorized representative
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• Owner Email — A reliable, monitored email address for the owner or authorized representative.
   
• Owner Phone — The best phone number to reach the owner or authorized representative directly. 
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• Retail Email & Phone — The store-level contact details used for customer or operations follow-up.
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• Select Your Store Type (SIC Classification)

‍‍YourYour SIC (Standard Industry Classification) just describes your type of business. It may seem a bit rigid, but because OTC and healthy benefit programs work with healthcare, these codes are very important. You just need to pick the store type that best fits your business. ‍

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Overview of SIC Store Types

Here is a brief overview of the different SIC types in the form. 

• Supermarket - a large grocery store with 2 or more lanes
• Bodega - a small grocery store with 1 lane
• Pharmacy - a store that sells prescription medicine and OTC products 
• Meat / Fish Market - a grocery that specializes in meat and seafood
• Produce / Farmer’s Market - a small grocery that specializes in fresh fruits and vegetables
• Mobile market - a very small store without a brick and mortar location e.g. a fruit cart 
• Convenience Store - a retail store that sells prepackaged snacks and convenience foods 
• Tobacco Store - a retail store that sells cigarettes and tobacco products and maybe other classifications of products 
• Liquor Store- a retail store that sells beer, wine, liquor, and maybe other classifications of products*
• Restaurant - a store that sells hot food and prepared meals 
• General / retail - Any store that does not fit these categories as their primary business e.g. a discount store 

*Not supported at this time

Understand How Your Store Is Classified

SIC types are important for benefit administration, but not every business fits neatly into these categories, and some terms like “bodega” are specific to certain regions of the country. How can a business understand where they fit? 

There are two important criteria here: how large is your business and what commonly eligible products do you offer?

What’s your Business Size

Your business’s size for OTC purposes is simply how many checkout counters or POS systems do you have. Most businesses will have at least one, larger ones will have two or more, and a few mobile-centric businesses may do business entirely on a mobile device like a tablet or smartphone. 

What Commonly Eligible Product Classes Do You Offer

For commonly eligible products, think of the following categories or classes

• ● Bread & grains, nuts, and oils
• ● Fresh fruits and vegetables
• ● Meat, seafood, and dairy products
• ● Non-carbonated soft drinks (e.g. water, juice) 
• ● OTC medical products  
• ● Approved herbal products (tea, ginseng, etc.)

Enter your Retail Address

The last step is just to add your Retail Address exactly as it appears on your lease or business documents. 

If your business has multiple locations, please use the form for multiple-location retailers here. 

Review and Send! 

That’s it! Once you’ve completed the form, you’re ready to submit your form. ProHealth Connect will get back to you within 1-2 business days (or sooner if able) and get you on your way to accepting OTC and healthy-benefits cards at your store through one of our payment solutions. 

To learn more about the PHC payment solutions and to see which one is right for you, click here.

For any questions please feel free to reach out to support@prohealth-connect.com