How to Fill Out and Submit MEDCOM Form 756: Sections and Signing

MEDCOM Form 756 is the U.S. Army Medical Command consent form that authorizes your military healthcare providers to send and receive medical information with you by e-mail. To complete it, fill in your patient and sponsor identifying data at the top, read the conditions and risks in the middle of the form, then sign and date the bottom and deliver the form to the Patient Administration Division at the Military Treatment Facility where you get care. The sections below walk through each field and where to send it.

What the Form Authorizes

The full title is “Medical Record — Consent Form: Authorization To Send And Receive Medical Information By Electronic Mail.” Signing it lets a specific provider or treatment facility communicate with you about medical advice, education, and treatment by e-mail, including for any minor dependents or wards you list.

It does not release copies of your records to anyone. If your goal is to send inpatient records, outpatient summaries, or dental records to a civilian doctor, attorney, insurer, or school, you need DD Form 2870 instead. The two forms often travel together in the same administrative packet, so confirm which one is in front of you before you start writing.

Section I — Patient and Sponsor Data

The top block asks for your name (last, first, middle initial), date of birth in YYYYMMDD format, and the last four digits of your Social Security number. The form asks only for the last four, not the full SSN. Below that, enter the e-mail address you want providers to use and a phone number.¹

A second block captures sponsor information. If you are the service member, you still complete it: name, rank or grade, organization, sex, year of birth, component and status, department or service branch, and the family member prefix paired with the last four of your SSN. For a dependent, enter the relationship to the sponsor in the appropriate field and fill the sponsor’s identifying details in the same block.¹

Sections II and III — Conditions and Risks You Accept by Signing

These sections are not blanks. They are disclosures you accept when you sign the form, and they set the boundaries of the e-mail relationship. Section II sets out the conditions:

E-mail is not appropriate for urgent or emergency situations. Call your MTF or go to the emergency room instead.
If a matter is complex or sensitive enough that a brief message will not cover it, schedule an appointment.
E-mail should not be used for discussions about sexually transmitted diseases, HIV/AIDS, spouse or child abuse, or chemical dependency.
MTF or dental treatment facility staff beyond your individual provider may receive and read the messages.
E-mails related to health consultation are copied, pasted, and filed as part of your medical record.

Section III warns about the inherent risks of e-mail. Messages can be intercepted, altered, forwarded, or used without your knowledge. Senders can mistype an address. Technical failures can cause a message to be lost during composition, transmission, or storage.¹ Read both sections before signing, because your signature acknowledges you understood them.

Section IV — Patient Guidelines

Section IV tells you how to format your e-mails once the consent is active. Put the topic of your message in the subject line (appointment, prescription, medical advice). In the body, include the patient’s name, phone number, family member prefix, and the last four of the sponsor’s SSN, formatted like “30/0858.” Acknowledge receipt of e-mails when a provider asks you to.

One item here catches people out: if your e-mail address changes, you have to complete a new MEDCOM Form 756. The old consent stays tied to the old address and does not carry over.¹

Section V — Signing the Form

Sign and date the bottom. Your signature acknowledges the privacy risks of e-mail and authorizes providers to communicate with you, and with any minor dependents or wards you have listed, for medical advice, education, and treatment. The form also notes that the provider may terminate the e-mail relationship if you repeatedly fail to follow the Section IV guidelines.¹

Where to Get the Form and Where to Submit It

Blank copies are available in person at the Patient Administration Division of any Military Treatment Facility, and the form is posted on MTF websites and on the Army Human Resources Command site as part of various administrative packets.²

Once the form is completed, deliver it to the Patient Administration Division at the MTF where you receive care. Most facilities accept forms in person, by secure fax, or by mail. Some also accept submissions by e-mail to their release-of-information address or through the DoD Secure Access File Exchange (SAFE) system.³ Methods and fax numbers vary by facility. Call the Patient Administration Division at your MTF before sending anything, confirm what they accept, and get the correct fax number or e-mail address.

Revoking Your Authorization

You can revoke MEDCOM Form 756 at any time, but the revocation has to be in writing. Send it to the MTF where the consent is on file, and the facility will stop e-mailing you.¹

A revocation is not retroactive. Any e-mails the facility already sent based on your valid authorization before it received your written revocation remain lawful. The revocation stops future action under that specific consent.⁴ Army Regulation 40-66 makes the same point: an individual may revoke in writing at any time, “except if the MTF/DTF has already taken action on the authorization.”⁵

When You Actually Need DD Form 2870 Instead

If you are trying to release copies of your medical or dental records to another person or organization (civilian doctor, attorney, insurer, school, or yourself), MEDCOM Form 756 will not do it. That release requires DD Form 2870, Authorization for Disclosure of Medical or Dental Information, which is a separate form downloadable from the Department of Defense forms website. Ask the Patient Administration Division at your MTF for a copy if you need one, and note that substance abuse records and psychotherapy notes each require their own standalone authorizations rather than DD Form 2870.⁶

1
Martin Army Community Hospital (TRICARE). MEDCOM Form 756 – Authorization to Send and Receive Medical Information By Electronic Mail
2
U.S. Army Human Resources Command. MEDCOM Form 756 Army Medical Record Consent
3
Carl R. Darnall Army Medical Center. Patient Administration Department
4
U.S. Department of Health and Human Services. Can an Individual Revoke His or Her Authorization
5
Department of the Army. Army Regulation 40-66 – Medical Services Medical Record Administration and Healthcare Documentation
6
Department of Defense. DD Form 2870 – Authorization for Disclosure of Medical or Dental Information