Navara Health — Authorization for Release of Protected Health Information

Practice (Releasing PHI)

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

Contact

469-653-3124
contact@navarahealthtx.com

Privacy Officer

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

Records Custodian

Navara Health, PLLC

Purpose of This Authorization

This Authorization permits Navara Health, PLLC to release specific Protected Health Information (PHI) about you to a specific person or organization that you designate. This is different from disclosures that are already permitted under HIPAA for treatment, payment, or healthcare operations (which do not require your separate written authorization).

This form is for specific disclosures. Use this form when you want Navara Health to release your records to a third party — for example, another doctor, an insurance company, an employer, an attorney, a family member, or for personal reasons. You do NOT need to use this form for ordinary treatment coordination with other providers we are already working with on your care.

Patient Information

Patient Full Legal Name

Date of Birth

Address

Phone Number

Last 4 of SSN (if needed for ID verification)

Who May Receive My PHI (Recipient)

Identify the person or organization that is authorized to receive my PHI:

Recipient Name (Person or Organization)

Relationship to Patient (if individual)

Recipient Address

City / State / ZIP

Recipient Phone

Recipient Fax

Recipient Email (for encrypted delivery only)

What Information May Be Released

Select all categories of PHI that may be released. Be as specific as possible.

Complete medical record — all records of evaluation, treatment, and communications
Office visit notes — clinical progress notes from specific dates (specify below)
Laboratory results — blood, urine, saliva, or other lab testing
Imaging — any imaging reports or results
Medication and prescription history — current and past prescriptions
Hormone therapy records — BHRT, TRT, thyroid, GLP-1, or other hormone-related care
Aesthetic procedure records — Vampire procedures, microneedling, neurotoxin, filler, IV therapy
Peptide therapy records — including specific peptides prescribed
Photographs — clinical or before/after photographs (if any)
Billing and payment records
Insurance information (if any)
Consent forms signed
Other (specify): ____________________________________________

Date Range of Records to Release

From (Date)

To (Date)

If you want all records, check here: [ ] All records from initial Navara visit to present

Special Protections — Specific Authorization Required

The following types of records receive enhanced legal protection and require specific authorization to be released. Check the box(es) that apply if you want these records released:

Enhanced Protection

Mental Health Records (excluding psychotherapy notes)

[ ] I specifically authorize the release of any mental health records (excluding psychotherapy notes, which generally require separate authorization).

Enhanced Protection

Substance Use Disorder Records (42 CFR Part 2)

SUD records are protected under federal law (42 CFR Part 2). Specific authorization required.

[ ] I specifically authorize the release of any substance use disorder records.

If authorized: Re-disclosure of these records by the recipient is prohibited unless further consent is obtained, in accordance with 42 CFR Part 2.

Enhanced Protection

HIV / AIDS Records

[ ] I specifically authorize the release of any HIV or AIDS-related records, including testing, status, and treatment.

Enhanced Protection

Genetic Information

[ ] I specifically authorize the release of any genetic testing results or genetic information.

Enhanced Protection · 2024 HHS Reproductive Health Rule

Reproductive Healthcare Records

Under the 2024 HHS Final Rule on reproductive health privacy, reproductive healthcare information receives heightened protection. Navara Health is prohibited from disclosing reproductive health PHI for proceedings investigating someone for seeking, obtaining, providing, or facilitating reproductive healthcare that was lawful where provided.

[ ] I specifically authorize the release of reproductive healthcare records (hormone therapy, contraception, pregnancy, fertility, gender-affirming care, or other reproductive-related information).

[ ] I understand that Navara Health may require additional attestation from the recipient confirming this authorization is not for a prohibited purpose under the 2024 Final Rule.

Purpose of This Disclosure

State the purpose for the release. (HIPAA requires this. You may state "at my request" if you prefer not to provide a detailed reason.)

Continuing medical care with another provider
Insurance claim or coverage determination
Legal proceedings or attorney representation
Employment or disability claim
Personal records
Family member or designated personal representative
At my request (no specific reason required)
Other (describe): __________________________________________

Expiration of This Authorization

HIPAA requires that this authorization specify when it expires. Choose one:

Expires on a specific date: ___________________ (date)
Expires after a specific event: ______________________________________________ (describe event, e.g., "completion of legal case," "after lab results delivered")
Expires one year from the date of signature (default if no other selection made)
Expires on the date my care at Navara Health ends

Method of Delivery

How would you like the records delivered?

Secure encrypted email to the recipient email address listed in Section 2
Secure fax to the recipient fax listed in Section 2
U.S. Mail to the recipient address listed in Section 2 (paper records)
Patient pickup — I will pick up records in person with photo ID
Through patient portal — I will download records myself and forward
Other (specify): ___________________________________________

A reasonable cost-based fee may apply for paper copies or large-volume electronic records (consistent with Texas HB 300 and HIPAA right of access rules).

Your Rights Under This Authorization

Important Patient Rights

By signing this Authorization, you understand and agree:

Right to revoke: You may revoke this Authorization at any time by submitting a written revocation to Navara Health. Revocation is effective when received, except to the extent that Navara Health has already acted in reliance on the Authorization.
Conditioning of treatment: Navara Health cannot condition your treatment, payment, enrollment, or eligibility for benefits on whether you sign this Authorization, except in limited circumstances (research-related treatment; healthcare for the sole purpose of creating PHI for a third party).
Re-disclosure: Information disclosed pursuant to this Authorization may no longer be protected by HIPAA once received by the recipient and may be subject to re-disclosure by the recipient, unless protected by other laws (e.g., 42 CFR Part 2 SUD records).
Right to a copy: You have the right to receive a copy of this signed Authorization.

Signature

I have read and understand this Authorization for Release of Protected Health Information. I have completed all sections that apply to my request. I voluntarily authorize Navara Health to release the information specified above for the purposes stated above.

Patient Signature (or Personal Representative)

Date

Printed Name

Date of Birth

If Signed by Personal Representative: Printed Name

Relationship / Legal Authority

Description of Authority Documentation (e.g., POA, Court Order)

Date Authority Verified

Staff Use Only

Authorization Received By (Staff Member)

Date Received

Patient Identity Verified Via

Date Records Released

Records Released Via (method)

Tracking / Confirmation #

Notes (special handling, reproductive health attestation obtained, SUD re-disclosure notice attached, etc.)