List the three components of a valid authorization

The specific name or general designation of the program or person permitted to make the disclosure.
The name or title of the individual or the name of the organization to which the disclosure is to be made.
The name of the patient
The purpose of the disclosure
How much and what kind of information is to be disclosed.
The signature of the patient and, when required for a patient who is a minor, the signature of a person authorized to give consent.
The date on which the consent is signed.
A statement that the consent is subject to revocation at any time except to the extent that the program or person which is to make the disclosure has already acted in reliance on it.
The date, event, or condition upon which the consent will expire if not revoked before.