Navara Health — Telemedicine Informed Consent

Practice

Navara Health, PLLC
5301 Alpha Road, Suite 34, Room 21
Dallas, Texas 75240

Contact

469-653-3124
contact@navarahealthtx.com

Treating Provider

Jessica Boggs, MSN, APRN, FNP-C, ENP-C

Medical Director

Simal Patel, MD

Telehealth Service States (Adults 18+)

Texas Colorado Connecticut Florida Iowa Oklahoma Vermont Virginia Washington

Controlled Substance Prescribing

Texas Only · In-Person Evaluation Required

Purpose of This Consent

This document is the master telemedicine informed consent for the practitioner-patient relationship I am establishing or maintaining with Navara Health, PLLC. It addresses the nature, benefits, risks, limitations, regulatory framework, and confidentiality of telemedicine services as practiced at Navara Health. This consent applies to all telemedicine encounters unless I revoke it in writing.

Companion Documents. This telemedicine consent complements but does not replace any procedure- or treatment-specific consent (such as the GLP-1, BHRT, peptide, or other consents you may sign during your care). State law in Florida, Texas, and certain other jurisdictions requires a specific telemedicine consent, which this document satisfies.

Introduction to Telemedicine

Telemedicine (also referred to as telehealth) involves the use of electronic communications and technology to provide healthcare services when the patient and provider are in different locations. Telemedicine services at Navara Health may include, but are not limited to:

Live two-way audio and/or video consultations
Telephone visits where clinically appropriate
Secure electronic messaging through the patient portal
Review of medical records, intake forms, questionnaires, images, and lab results
Follow-up care, education, and treatment planning
Prescription management (for medications and services Navara Health is authorized to prescribe under the applicable state's laws)

Electronic systems used by Navara Health incorporate security measures designed to protect the confidentiality, integrity, and availability of personal health information in accordance with HIPAA and applicable state and federal laws.

Multi-State Licensure Framework

Jessica Boggs, APRN holds active nurse practitioner licensure and prescribing authority in the following states. I confirm that I will be physically located in one of these states at the time of each telemedicine visit:

Texas — practice home state
Colorado
Connecticut
Florida
Iowa
Oklahoma
Vermont
Virginia
Washington

I agree to immediately notify Navara Health if my physical location changes during the course of care, particularly if I move to a state where Jessica Boggs APRN does not hold licensure. Care cannot lawfully be provided across state lines outside of the states listed above.

State Verification at Each Visit. At each telemedicine visit, I may be asked to confirm my physical location to verify telehealth authority. Misrepresenting my location to receive care from a state where the provider is not licensed may constitute fraud and will result in immediate termination of services.

Controlled Substances & Ryan Haight Act

Federal Citation · Ryan Haight Online Pharmacy Consumer Protection Act of 2008

Federal law — specifically, the Ryan Haight Online Pharmacy Consumer Protection Act of 2008 and the Controlled Substances Act, as enforced by the U.S. Drug Enforcement Administration (DEA) — regulates the prescribing of controlled substances via telemedicine. With certain limited exceptions, federal law generally requires at least one in-person medical evaluation before a controlled substance can be prescribed via telemedicine.

Additionally, the Texas Medical Board and Texas Board of Nursing have parallel requirements for controlled substance prescribing within Texas, including periodic in-person re-evaluation.

Accordingly, I understand and agree that:

Controlled substance prescribing at Navara Health is limited to Texas patients only and requires an in-person evaluation at the Dallas clinic location
This applies to all DEA Schedule II–V medications, including testosterone (Schedule III)
Periodic in-person re-evaluation is required to continue controlled substance prescribing, per Texas Medical Board and Texas Board of Nursing requirements
Patients in any other licensed state may receive non-controlled telehealth services but cannot be prescribed controlled substances via telehealth, regardless of multi-state licensing
Additional documentation, including the Testosterone Therapy Controlled Substance Agreement and the ID Verification Consent, applies to all controlled substance prescribing and is incorporated by reference

Pregnancy & Reproductive Health Considerations

I understand and agree that:

Many therapies prescribed at Navara Health — including hormone therapy, GLP-1 medications, certain peptides, and other treatments — are not recommended during pregnancy or breastfeeding
Some states have specific regulations restricting telehealth provision of certain reproductive and hormone-related services; Navara Health follows the applicable laws of each licensed state
I will notify Navara Health immediately if I become pregnant, am planning pregnancy, or am breastfeeding
Pregnancy may necessitate modification, suspension, or discontinuation of therapy
Women of reproductive potential receiving therapies that may affect pregnancy are responsible for using effective contraception as discussed with their provider
Navara Health may require pregnancy testing in clinically appropriate circumstances

Expected Benefits of Telemedicine

Potential benefits of telemedicine may include:

Improved access to care without the need for travel or in-person visits
Increased convenience and scheduling flexibility
Timely evaluation, education, and follow-up
Continuity of care when in-person visits are not practical
Reduced exposure to infectious disease in waiting rooms
Access to specialty care that may not be readily available in my local area

Possible Risks & Limitations

As with any medical service, telemedicine has potential risks and limitations, including but not limited to:

Technical issues such as poor connection, audio/video failure, dropped calls, or system outages
Incomplete transmission of information that may limit clinical assessment
Delays in care due to technology malfunction, scheduling issues, or platform availability
Limitations in physical examination — telemedicine cannot fully substitute for in-person examination (e.g., palpation, auscultation, certain visual inspections)
Risk of adverse outcomes if critical information is unavailable, incomplete, or transmitted inaccurately
Rare breaches of privacy despite reasonable security safeguards on practice systems
Patient-side privacy issues if I am not in a private location during my visit (others in my home or workplace overhearing)
Differences in care quality compared to traditional in-person visits for certain conditions

I understand that telemedicine may not be appropriate for all conditions and that I may be directed to seek in-person care or emergency services when necessary.

Privacy, Confidentiality & Recording

Privacy & Recording — Important

Recording of Telehealth Visits

I understand and agree that:

Navara Health does not record audio or video of telehealth visits by default. If, for any clinical or operational reason, a visit is to be recorded, I will be informed in advance and asked for explicit consent.
I will not record audio or video of my telehealth visits without first asking my provider and receiving permission. This applies to screen recording, screenshot capture, third-party recording apps, and any other method.
While Texas is a one-party consent state for audio recording, my provider asks that I extend the courtesy of asking before recording so that the visit can be conducted with full awareness.
If I share, post, or publish a recording of my telehealth visit publicly (on social media or otherwise), I am responsible for any privacy implications, including any references to my provider, the practice, or any other person.
I will not record any portion of a visit during which another patient, staff member, or third party may be visible or audible without their explicit permission.
I will conduct my telehealth visits in a private location where my conversation cannot be overheard by unauthorized persons, to protect my own privacy.

General Confidentiality

Laws protecting the privacy and confidentiality of medical information apply to telemedicine. My information will not be shared without authorization except as permitted or required by law (treatment, payment, healthcare operations, public health reporting, or court order). The practice's full HIPAA Notice of Privacy Practices applies and is incorporated by reference.

AI Scribes, Transcription & Documentation Tools

Documentation Technology Disclosure & Opt-In

Use of AI-Assisted Clinical Documentation

Navara Health may, from time to time, use AI-assisted clinical documentation tools (often called "AI scribes," "ambient AI," or "ambient transcription"). These tools listen to portions of a clinical visit and assist the provider in generating clinical notes. They may also be used for telephone-call summarization or message drafting.

I understand that:

If an AI scribe or ambient transcription tool is used, it operates within a HIPAA Business Associate Agreement with the vendor
Audio is typically processed and deleted after note generation, not retained indefinitely
The provider remains responsible for reviewing and approving any AI-generated note before it becomes part of the medical record
AI scribes are intended to improve documentation accuracy and free the provider to focus on the patient, not to replace clinical judgment
I have the right to opt out of AI scribe use at any visit by selecting Option B below or by verbally requesting the AI scribe be turned off at any point during the visit

Please initial ONE option below:

Option A · Consent to AI Scribe / Ambient Documentation I consent to the use of AI-assisted clinical documentation tools during my telemedicine visits when Navara Health chooses to use them. I understand the audio is used to generate clinical notes and is governed by a HIPAA Business Associate Agreement with the vendor. I may revoke this consent at any time.

Option B · Decline AI Scribe / Ambient Documentation I decline use of AI scribes or ambient documentation tools during my telemedicine visits. My provider will document the visit through traditional manual methods. I understand my visits may take longer due to manual documentation.

Option C · Not Applicable Navara Health does not currently use AI scribe tools in my visits. If this changes, I will be informed and asked to re-affirm my preference at that time.

Patient Signature (AI Scribe Preference)

Date

Patient Rights & Acknowledgments

By signing this form, I acknowledge and understand that I have the right to:

Refuse or withdraw consent to telemedicine services at any time without affecting my right to future care or treatment in person
Inspect and obtain copies of my medical records related to telemedicine encounters, subject to reasonable fees as permitted by law
Request an in-person visit as an alternative to a telemedicine visit, subject to scheduling and the provider's clinical judgment that in-person care is appropriate
Receive accurate information about my health, treatment options, and the limitations of telemedicine
Be treated with dignity and respect during telemedicine encounters
File a privacy complaint with Navara Health, the U.S. Department of Health and Human Services Office for Civil Rights, or my state regulator without retaliation

Patient Responsibilities

I agree to:

Provide accurate and complete medical information, including prior diagnoses, medications, supplements, allergies, and current symptoms
Inform my provider of any care I receive from other healthcare professionals, including primary care, specialists, urgent care, and emergency visits
Use a device and connection capable of supporting reliable audio/video communication
Be in a private location during my visit to protect my own confidentiality
Verify my physical location and identity at the start of each visit as requested
Update my government-issued ID on file if it changes (per the ID Verification Consent)
Disclose if I am recording the visit or have any other person present
Follow through with recommended labs, follow-up, and treatment as discussed during my visit
Notify Navara Health promptly of any adverse events, new symptoms, or significant medical changes

No Guarantee of Results

I understand that while telemedicine may provide benefit, no specific outcomes or results are guaranteed. Clinical response varies between individuals, and the provider's judgment and recommendations are based on the information available at the time of the visit.

Emergency Notice

Telemedicine Is Not For Emergencies

If I experience any of the following, I will call 911 or go to the nearest emergency department immediately, not attempt to reach my provider through telehealth:

Chest pain, pressure, or symptoms of heart attack
Symptoms of stroke (sudden weakness, vision changes, speech difficulty)
Severe difficulty breathing
Severe bleeding
Anaphylaxis or severe allergic reaction
Loss of consciousness
Severe injury or accident
Thoughts of self-harm or suicide

For mental health crises, call or text 988 (Suicide & Crisis Lifeline).

Navara Health is a non-emergency practice and does not provide emergency care, urgent in-person evaluation, or after-hours emergency services. I will not rely on telemedicine for urgent or emergent situations.

Right to Withdraw Consent

I may withdraw my consent to telemedicine services at any time by submitting a written request to contact@navarahealthtx.com. Withdrawal of consent applies to future telemedicine visits and does not affect care already provided. Withdrawal does not affect my right to seek in-person care or to seek care from other providers.

Dispute Resolution & Governing Law

Any dispute, controversy, or claim arising out of or relating to this Consent or telemedicine services provided by Navara Health shall first be addressed by good-faith negotiation. If not resolved within thirty (30) days, the parties agree to submit the dispute to binding arbitration in Dallas County, Texas, under the rules of a recognized arbitration body, unless otherwise required by the laws of the patient's state of residence. The parties waive the right to a jury trial.

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

Patient Initials — Required for Each Critical Clause

Each of the following requires my separate written initials.

I confirm that I will be physically located in one of the nine licensed states at the time of each telemedicine visit, and I will notify Navara Health immediately if my location changes.

Initials

I understand that controlled substance prescribing (including testosterone) is limited to Texas patients only, requires in-person evaluation, and is governed by the Ryan Haight Act and Texas Medical Board / Board of Nursing rules.

Initials

I understand the limitations of telemedicine, including reduced physical examination capability and possible technical issues, and that in-person care may be required for certain conditions.

Initials

I will not record any telemedicine visit without first asking my provider and receiving permission, and I will not publish or share any recording involving other patients or staff.

Initials

I have completed the AI Scribe Preference selection in Section 8.

Initials

I understand telemedicine is not for emergencies and I will call 911 or go to the nearest emergency department for emergencies, and 988 for mental health crises.

Initials

I agree to binding arbitration as described in Section 14 and understand that I am waiving the right to a jury trial.

Initials

Acknowledgment & Electronic Consent

By signing below (or by typing my full legal name as an electronic signature), I confirm and agree:

I am at least 18 years of age.
I have read and understand this Telemedicine Informed Consent in its entirety.
I understand the licensure framework, controlled substance limitations, and pregnancy-related considerations.
I understand the privacy, confidentiality, and recording provisions in Section 7.
I have completed the AI Scribe Preference selection in Section 8 and the Patient Initials block above.
I have had the opportunity to ask questions, and all questions have been answered to my satisfaction.
I voluntarily consent to receive healthcare services via telemedicine from Navara Health, PLLC.
I authorize communication with Navara Health through the channels described in this consent and in companion practice consents.
I agree to binding arbitration as described in Section 14.
My typed name serves as my legal electronic signature, equivalent to a handwritten signature, and this consent becomes part of my permanent medical record.

Patient Printed Name

Date of Birth

State of Residence at Time of Signing

Date

Patient Signature (or Typed Electronic Signature)

Date

Provider Signature — Jessica Boggs, APRN, FNP-C, ENP-C

Date