Practice
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
NPP Effective Date
May 2026
Purpose of This Acknowledgment
Federal HIPAA regulations (45 CFR § 164.520(c)(2)) require that Navara Health, PLLC make a good-faith effort to obtain written acknowledgment that you have received our Notice of Privacy Practices (NPP). This Acknowledgment confirms only that you received the Notice — it does not authorize any use or disclosure of your protected health information beyond what is already permitted under HIPAA.
This is not a consent form. Signing this Acknowledgment does not waive any of your privacy rights. It simply documents that the Notice of Privacy Practices was provided to you, in compliance with HIPAA's requirement that covered entities make a good-faith effort to obtain written acknowledgment.
What I Am Acknowledging
By signing below, I acknowledge that:
- I have received a copy of the Navara Health, PLLC Notice of Privacy Practices (effective May 2026).
- I have had the opportunity to read the Notice and ask questions.
- I understand the Notice describes how my Protected Health Information (PHI) may be used and disclosed, and my rights regarding that information.
- I understand that the Notice is also publicly posted at www.navarahealthtx.com and in the practice waiting area.
- I understand that Navara Health may revise the Notice from time to time, and that the current version always governs.
- I may request a paper copy of the Notice at any time, free of charge.
- I understand that this Acknowledgment does not authorize disclosure of my PHI beyond what is already permitted by HIPAA.
Patient Signature
Patient Signature (or Typed Electronic Signature)
Personal Representative Name (if applicable)
Staff Use Only: Documentation If Patient Declines to Sign
For Staff Use Only — HIPAA Good-Faith Effort Documentation
Patient Declined to Sign Acknowledgment
If the patient declines to sign the Acknowledgment of Receipt, HIPAA requires Navara Health to document a good-faith effort to obtain it. Complete this section only if the patient was provided the Notice but declined to sign.
Reason patient declined (check all that apply or describe):
- Patient declined without giving a reason
- Patient was unable to sign (specify reason): __________________________________
- Patient stated they did not wish to sign but acknowledged verbally
- Other (describe): __________________________________
Patient Name (for documentation)
Note: A patient's refusal to sign this Acknowledgment does not prevent them from receiving care. The patient retains all rights described in the Notice of Privacy Practices regardless of whether the Acknowledgment is signed.