The form for the authorization of installation and use of a monitoring device shall provide for:

1. A. consent of the patient or surrogate authorizing the installation and use of the monitoring device;
2. B. notice to the facility of the patient’s installation of a monitoring device and specifics as to its type, function and use;
3. C. consent of any roommate, or that roommate’s surrogate;
4. D. notice of release from liability for privacy violation through the use of the monitoring device; and
5. E. waiver of the patient’s right to privacy in conjunction with the use of the monitoring device.

[9.2.23.14 NMAC - N, 7/15/04]