The form for the authorization of installation and use of a monitoring device shall provide for:
A. consent of the patient or the surrogate authorizing the installation and use of the monitoring device;
B. notice to the facility of the patient's installation of a monitoring device and specifics as to its type, function and use;
C. consent of any other patient or that patient's surrogate sharing the same room;
D. notice of release from liability for privacy violation through the use of the monitoring device; and
E. waiver of the patient's right to privacy in conjunction with the use of the monitoring device.