(a) A provider shall provide to a patient whose data is being collected under this chapter written notice on a form prescribed by the department of the collection of the patient’s data for health care purposes.
(b) The notice provided under this section must include the name of the agency or entity receiving the data and of an individual within the agency or entity whom the patient may contact regarding the collection of data.

(c) The department shall include the notice required under this section on an existing department form and make the form available on the department’s Internet website.