(A) A health care provider may refer a patient to an entity in which the health care provider is an investor if the referral is permitted under Section 44-113-20(10)(d) or Section 44-113-30(A)(3) if before the referral the provider furnishes the patient with a written disclosure form informing the patient of:

1. (1) the existence of the investment interest;
2. (2) the name and address of each applicable entity to which a referral is made in which the referring health care provider is an investor;
3. (3) the patient's right to obtain the item or services for which the patient has been referred at the location or from the provider or supplier of the patient's choice, including the entity in which the referring provider is an investor;
4. (4) the names and addresses of at least two alternative sources of these items or services available to the patient;
5. (5) a schedule of typical fees for items or services usually provided by the entity or, if impracticable because of the nature of the treatment, a written estimate specific to the patient.