A patient of 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 e disclosed;4. The specific information to be disclosed;5. The purpose for the disclosure;6. The date the consent was signed and the signature of the individual witnessing the consent;7. The signature of the patient, parent, guardian or authorized representative; and8. A notice that the consent is valid only for a specified period of time.15 Miss. Code. R. § 16-1-51.31.4
Miss. Code Ann. § 43-11-13