An authorization for an employer to disclose medical information shall be valid if it complies with all of the following:
(a)
Is handwritten by the person who signs it or is in a typeface no smaller than 14-point type.
(b)
Is clearly separate from any other language present on the same page and is executed by a signature that serves no purpose other than to execute the authorization.
(c)
Is signed and dated by one of the following:
(1)
The patient, except that a patient who is a minor may only sign an authorization for the disclosure of medical information obtained by a provider of health care in the course of furnishing services to which the minor could lawfully have consented under Part 1 (commencing with Section 25) or Part 2.7 (commencing with Section 60) of Division 1.
(2)
The legal representative of the patient, if the patient is a minor or incompetent. However, authorization may not be given under this subdivision for the disclosure of medical information that pertains to a competent minor and that was created by a provider of health care in the course of furnishing services to which a minor patient could lawfully have consented under Part 1 (commencing with Section 25) or Part 2.7 (commencing with Section 60) of Division 1.
(3)
The beneficiary or personal representative of a deceased patient.
(d)
States the limitations, if any, on the types of medical information to be disclosed.
(e)
States the name or functions of the employer or person authorized to disclose the medical information.
(f)
States the names or functions of the persons or entities authorized to receive the medical information.
(g)
States the limitations, if any, on the use of the medical information by the persons or entities authorized to receive the medical information.
(h)
States a specific date after which the employer is no longer authorized to disclose the medical information.
(i)
Advises the person who signed the authorization of the right to receive a copy of the authorization.