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AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION You May Refuse to Sign This Authorization I, (name of individual) authorize (name of school) to use and disclose in any form or
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You may refuse to provide any information that you believe may incriminate you.
Individuals who are directly involved in a legal matter may be required to file a 'refusal to incriminate' form.
You can fill out the 'refusal to incriminate' form by stating your reasons for refusing to provide certain information.
The purpose of 'refusal to incriminate' is to protect individuals from self-incrimination under the law.
The 'refusal to incriminate' form must detail the specific information being refused and the reasons for refusal.
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