1. (1) the name of the service that is to make the notification;
2. (2) the name of the person or persons to whom the notification is made;
3. (3) the name of the client or patient receiving the service;
4. (4) the purpose or need for the notification;
5. (5) the nature of extent of information to be disclosed;
6. (6) a statement that the consent may be revoked by the patient/client at any time except to the extent that action has been taken thereon and a specification of the date, event or condition upon which it will expire without express revocation;
7. (7) the date on which the form is signed; and

8. (8) the signature of the client or patient.

   (c) Notification without consent.

   Whenever a person who is suffering from a serious medical condition and is incapable of rational communication is being treated at a designated facility or service, the treating physician may, in his discretion, give notification of such person's whereabouts and condition to a member of the person's family or to a significant other with whom such person is known to have a responsible personal relationship.

(a) Notification with consent.

Staff of an emergency care service may notify family members or other individuals of a person's presence at the service if the person gives written consent to such notification in accordance with subdivision (b) of this section.

(b) Notification consent form.

Consent for notification of family or significant others of a person's receipt, attempted receipt or refusal to receive emergency care shall be in writing and shall contain the following: