Purpose of Authorization: By signing this authorization form, I am providing Breakthrough Solutions Worldwide, Inc. to distribute and share my client testimonial that I provided.  I agree that I am voluntarily sharing my testimonial about services from Breakthrough Solutions Worldwide, Inc., and I am receiving no financial remuneration from Breakthrough Solutions Worldwide, Inc. for providing my testimonial.  Breakthrough Solutions Worldwide, Inc. has permission to record, publish, or display testimonials, statements, pictures, or recordings provided from me in any media, by any methods or means including, but not limited to, educational, advertising, social media, marketing and promotional materials.

Components of my testimonial: I agree that the foregoing testimonial represents a “Statement or Testimonial” by me, as defined in that certain General Release signed by me and is subject to the terms and conditions of such General Release. I waive the right of prior approval of any possible edits before publication and hereby release Breakthrough Solutions Worldwide, Inc. from any and all claims for damages of any kind based on the use of my testimonial or information in the testimonial.

Private Clients and Group Participants: I understand that all other protected health information that Breakthrough Solutions Worldwide, Inc. creates and maintains for purposes of my care will not be used in my testimonial or for marketing purposes without prior authorization per privacy regulations of the state and Health Insurance Portability and Accountability Act (HIPAA).  Please understand that by sharing your testimonial, there are possible risks (such as a loss of a certain level of confidentiality) and the possible benefits (it may help others).

By signing below I warrant that I am over the age of eighteen (18) years.  I agree and acknowledge that and have read and understood the above release and agree to all terms described.  This consent is granted for an undefined period. I may revoke this permission in writing at any time.