Service Request

Request For PHCProducts & Services

PRIVACY ACT STATEMENT

AUTHORITY: 5 U.S.C. 1302, 2951, 3301, 3372, 4118, 8347, and Executive Orders 9397, 9830, and 12107.

PRINCIPAL PURPOSE(S): To verify an individual's eligibility for the request for products/services, authentication of identity and identification of customers.

ROUTINE USE(S): Information provided will be used only within USAPHC and will not be released to any other staff activity.

DISCLOSURE: Information is voluntary, however, failure to provide all the requested information could lead to disapproval of the request for products/services.

SECURITY CLASSIFICATION STATEMENT: It is incumbent upon customers providing information and data to this Program/Institute/Command to ensure that consolidation of that information and data will not result in an increase in security classification. Developers must use the SIPRNET to communicate information and data in situations where a resulting increase in security classification is reasonably foreseeable.

1) Hello PHC customer!

I am... (select one)

an external PHC CUSTOMER

a PHC EMPLOYEE requesting an internal product or service, or requesting internal training

a PHC EMPLOYEE filling out this form on behalf of a PHC EXTERNAL CUSTOMER.
(Additional information is required for external customers.)

Help: USAPHC-CPMOAdministrator@amedd.army.mil

	an external PHC CUSTOMER
	a PHC EMPLOYEE requesting an internal product or service, or requesting internal training
	a PHC EMPLOYEE filling out this form on behalf of a PHC EXTERNAL CUSTOMER. (Additional information is required for external customers.)