A patient or his or her authorized representative may consent to the release of information provided that written consent is given on a form containing the following information:
3. the name of the person, agency or organization to which the information is to be disclosed4. the specific information to be disclosed5. the purpose for the disclosure6. the date the consent was signed and the signature of the individual witnessing the consent7. the signature of the patient, guardian or authorized representative, and8. a notice that the consent is valid only for a specified period of time.15 Miss. Code. R. 16-1-52.9.4
Miss. Code Ann. § 41-9-17