A long-term care facility may prescribe a form for use by a resident or resident’s guardian or attorney in fact seeking to authorize the installation and use of an electronic monitoring device in the resident’s room in a long-term care facility. If a long-term care facility prescribes a form, it shall, at a minimum, include all of the following:

(A) An explanation of sections 3721.60 to 3721.67 of the Revised Code;

(B) An acknowledgment that the resident or resident’s guardian or attorney in fact has consented to the installation and use of the device in the resident’s room;

(C) In the case of a resident who lives in a room with another resident, an acknowledgment that the other resident or other resident’s guardian or attorney in fact has consented to the installation and use of the device and a description of any conditions placed on that consent pursuant to division (B)(2) of section 3721.62 of the Revised Code;

(D) A section for providing the facility with information regarding the type, function, and use of the device to be installed and used;

(E) A section stating that the facility is released from liability in any civil or criminal action or administrative proceeding for a violation of the resident’s right to privacy in connection with using the device.