The express authorization required pursuant to this chapter shall meet the following requirements when the information is requested by third parties:(a) The specific name of the institutional provider authorized to disclose the information;(b) the name of the natural or juridical person authorized to receive the information;(c) the name of the person who consents to the disclosure. When other than the person who receives mental healthcare services, a sworn statement shall be included stating the source of his/her authority to give consent;(d) the specific information to be disclosed, which shall not include psychological testing protocols, information relative to other family members or to persons who have been involved in the treatment process, and/or notes containing the dialogue between the provider and the person who receives mental healthcare services during treatment sessions;(e) the specific purpose for which the information requested and authorized shall be used, and the signature;(f) the date when the consent is given;(g) the date of expiration of the consent given, and any condition or event that would invalidate the consent upon its occurrence;(h) notice of the fact

gnature;(f) the date when the consent is given;(g) the date of expiration of the consent given, and any condition or event that would invalidate the consent upon its occurrence;(h) notice of the fact that the participant may revoke the consent given at any time, and(i) the signature of the person giving the consent.The express authorization shall be made in a written document, which shall expire not later than twelve (12) months after the signature and date of issuance, without impairment of having the consent expiration date lapse at a shorter term or of the authorizer’s right to revoke said consent at any time. History —Oct. 2, 2000, No. 408, § 2.10; Aug. 6, 2008, No. 183, § 8.