General Informed Consent, Practice Policies
& HIPAA Acknowledgment

General Informed Consent for Care

By signing this document, I voluntarily consent to receive care from Navara Health, PLLC, including but not limited to:

• Medical evaluation, diagnosis, and treatment
• Nursing and clinical services
• Preventive, wellness, functional, integrative, and conventional medical care
• Aesthetic and cosmetic services
• Hormone optimization and metabolic health services
• Weight management and GLP-1 services
• Peptide therapy
• IV infusion and injectable wellness therapies
• Direct Primary Care (DPC) services where applicable
• Laboratory testing, imaging, and diagnostic procedures
• Prescription medications and supplements when clinically appropriate
• Telehealth services in states where the provider is licensed

I understand that:

• No guarantees have been made regarding outcomes
• Treatment recommendations may evolve based on clinical findings, labs, and response
• I may decline or withdraw consent for any treatment at any time
• Alternative treatment options may exist and can be discussed upon request
• Certain services require additional procedure-specific consents

I acknowledge that Navara Health is a teaching-friendly practice. I consent to supervised involvement of trainees (students, interns, fellows, residents, or medical assistants) when appropriate, with my prior knowledge.

Confidentiality & Limits of Privacy

My medical information is confidential and protected under federal and state law. My information will not be released without my written authorization except as permitted or required by law, including:

• Risk of serious harm to self or others
• Suspected abuse or neglect of a child, dependent adult, or elderly individual
• Court orders, subpoenas, or legal mandates
• Public health reporting requirements
• Controlled substance reporting requirements (PMP, DEA, law enforcement as required)
• Mandatory reporting under Texas law

Providers may consult with other clinicians involved in my care without using identifying information when appropriate. If I encounter my provider outside the clinic, they will not initiate contact in order to protect my privacy.

Telehealth Services

I consent to receive care via telehealth when appropriate. I understand that:

• Telehealth services are provided through HIPAA-compliant platforms
• I am responsible for ensuring privacy during my appointment
• Certain services may legally require in-person visits, including controlled substance prescribing
• I must not share my telehealth appointment access with others
• I must be physically located in a state where my provider is licensed at the time of service: Texas, Colorado, Connecticut, Florida, Iowa, Oklahoma, Vermont, Virginia, or Washington
• I will inform Navara Health promptly if I relocate or am temporarily located outside my listed state of residence
• Technology failures may interrupt visits; in such cases the visit will be rescheduled or transitioned to phone

Medication & Refill Policy

• Medication refill requests may take up to 3 business days to process
• Refill requests must be submitted through the patient portal or directly through the pharmacy
• Early refill requests may be denied
• Refills will not be issued if required monitoring labs are overdue, incomplete, or significantly abnormal
• Certain medications are regulated by federal and state law and may require additional monitoring or in-person visits
• Controlled stimulant medications (Adderall, Ritalin, Vyvanse, etc.) are not prescribed by this practice
• Benzodiazepines, opioids, controlled sleep medications, and other controlled substances are not prescribed except as described in Section 5

Controlled Substance Policy

If prescribed any controlled medication (including testosterone), I agree to:

• Take medications only as prescribed
• Disclose all medications, providers, and medical conditions
• Participate in Texas Prescription Monitoring Program (PMP) checks
• Submit to urine drug screening or other testing if required
• Secure medications appropriately
• Report loss or theft with a police report (replacement is not guaranteed and is generally not provided per DEA regulations)
• Sign and comply with any procedure-specific Controlled Substance Agreement

Failure to comply may result in modification or discontinuation of treatment and may result in dismissal from the practice.

Public Health & Safety

I understand that in-person visits carry a risk of exposure to infectious illnesses. If I am ill, I agree to notify the clinic in advance and request telehealth services when appropriate, or reschedule when telehealth is not appropriate. The practice may require masking, rescheduling, or telehealth conversion for patients with active respiratory symptoms.

Practice Policies

Communication & HIPAA Authorization

I authorize Navara Health to communicate with me regarding scheduling, clinical care, lab results, billing, and follow-up through:

• The secure HIPAA-compliant patient portal
• Email to the address I have provided
• SMS / text message to the mobile number I have provided
• Telephone calls to the number I have provided

I understand that email and SMS are not fully secure channels. I may revoke authorization for any specific channel in writing to contact@navarahealthtx.com, except where the channel is required for legally mandated notices.

HIPAA Notice of Privacy Practices

Navara Health protects your Protected Health Information (PHI) in accordance with the federal Health Insurance Portability and Accountability Act (HIPAA) and applicable Texas law.

PHI May Be Used or Disclosed For

• Treatment — providing, coordinating, or managing your healthcare
• Payment — billing, collections, and processing payment for services
• Healthcare operations — practice administration, quality improvement, training, and compliance

PHI May Be Shared With

• Providers and clinicians involved in your care
• Pharmacies
• Laboratories and imaging facilities
• Business associates (electronic health record vendors, billing services, compliance and consulting services) under written HIPAA business associate agreements
• Government agencies for public health reporting, controlled substance monitoring, and other legally required disclosures

Your Rights Under HIPAA

You have the right to:

• Access and receive copies of your medical records
• Request amendments to your medical records
• Receive an accounting of disclosures of your PHI
• Request restrictions on certain uses or disclosures of your PHI
• Request confidential communications (e.g., a specific phone number or address)
• Receive a paper copy of this Notice upon request
• Be notified of any breach of unsecured PHI
• File a privacy complaint with the practice or the U.S. Department of Health & Human Services without retaliation

Privacy Officer Contact

Jessica Boggs, MSN, APRN, FNP-C, ENP-C
Navara Health, PLLC
5301 Alpha Road, Suite 34, Room 21
Dallas, Texas 75240
469-653-3124
contact@navarahealthtx.com

Patient Rights & Responsibilities

Termination of the Practitioner-Patient Relationship

Navara Health reserves the right to terminate the practitioner-patient relationship with written notice for any of the following:

• Non-payment of fees after written notice
• Repeated non-compliance with the treatment plan
• Abusive, threatening, or harassing behavior toward providers, staff, or other patients
• Misrepresentation of medical history, identity, or insurance information
• Diversion, misuse, or attempted diversion of controlled substances
• Repeated no-shows or late cancellations
• Conduct that creates a clinical, legal, or safety risk for the practice

Where required by law, the practice will provide written notice and a reasonable continuity-of-care period (typically 30 days) for the patient to establish care elsewhere, except where immediate termination is warranted by safety concerns.

Dispute Resolution & Binding Arbitration

Any dispute, controversy, or claim arising out of or relating to this Consent, the services provided, or the practitioner-patient relationship — including any claim of medical malpractice, billing dispute, or breach of contract — shall first be addressed by good-faith negotiation between the parties.

If the matter cannot be resolved through negotiation within thirty (30) days, the parties agree to submit the dispute to binding arbitration administered by a recognized arbitration body (such as the American Arbitration Association) under its applicable rules, with the arbitration to take place in Dallas County, Texas, unless otherwise required by the laws of the patient's state of residence.

The parties acknowledge that by agreeing to arbitration, they are waiving the right to a jury trial. This provision does not waive any right that cannot lawfully be waived under the patient's state law. Either party retains the right to seek injunctive or equitable relief in court where appropriate.

Governing Law & Severability

This Consent shall be governed by and construed under the laws of the State of Texas, except where the laws of the patient's state of residence require otherwise for healthcare services delivered to residents of that state. If any provision is found unenforceable, the remaining provisions shall remain in full force and effect.

Emergency Disclaimer