15 Miss. Code. R. 16-1-40.23.4

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:

1. Name of patient;

2. Name of program;

3. The name of the person, agency or organization to which the information is to be 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; and

8. A notice that the consent is valid only for a specified period of time.

Notes

15 Miss. Code. R. 16-1-40.23.4

Miss. Code Ann. § 41-9-17