Release of Information

I have been informed that, in order to protect the limited confidentiality of records, my agreement to obtain or release information is necessary and that this permission is limited for the purposes and to the person listed above, and will be effective for 90 days after the date of my signature, unless otherwise specified below. I also understand that this consent is revocable, by contacting JGKA in writing, except to the extent that action has been taken in reliance thereon. We will not condition treatment, payment, or enrollment in services on the person providing authorization for the requested use or disclosure.