(A) For the purposes of section 5160.45 of the Revised Code, an authorization shall be made on a form that uses language understandable to the average person and contains all of the following:

1. (1) A description of the information to be used or disclosed that identifies the information in a specific and meaningful fashion;
2. (2) The name or other specific identification of the person or class of persons authorized to make the requested use or disclosure;
3. (3) The name or other specific identification of the person or government entity to which the information may be released;
4. (4) A description of each purpose of the requested use or disclosure of the information;
5. (5) The date on which the authorization expires or an event related either to the individual who is the subject of the request or to the purposes of the requested use or disclosure, the occurrence of which will cause the authorization to expire;
6. (6) A statement that the information used or disclosed pursuant to the authorization may be disclosed by the recipient of the information and may no longer be protected from disclosure;
7. (7) The signature of the individual or the individual's authorized representative and the date on which the authorization was signed;
8. (8) If signed by an authorized representative, a description of the representative's authority to act for the individual;

9. (9) A statement of the individual or authorized representative's right to prospectively revoke the written authorization in writing, along with either of the following:

   1. (a) A description of how the individual or authorized representative may revoke the authorization;
   2. (b) If the department of medicaid has established a privacy notice that contains a description of how the individual or authorized representative may revoke the authorization, a reference to the privacy notice.
10. (10) A statement that treatment, payment, enrollment, or eligibility for a medical assistance program cannot be conditioned on signing the authorization unless the authorization is necessary for determining eligibility for the program.