Practice
Navara Health, PLLC
5301 Alpha Road, Suite 34, Room 21
Dallas, Texas 75240
Contact
469-653-3124
contact@navarahealthtx.com
Purpose of This Consent
To comply with federal and state regulations — including identity verification requirements for prescribing medications and controlled substances — Navara Health, PLLC must verify my identity prior to treatment and prescription processing. I agree to provide accurate and valid government-issued identification as part of my medical record.
Why Identity Verification Is Required
Identity verification at Navara Health is required for:
- Age verification — confirming the patient is at least 18 years of age (Navara Health services are restricted to adults)
- Pharmacy orders for medications, including controlled substances and compounded preparations
- Compliance with DEA, Texas Medical Board, Texas Board of Nursing, and pharmacy regulations
- Ryan Haight Online Pharmacy Consumer Protection Act compliance for controlled substance prescribing via telemedicine
- Texas Prescription Monitoring Program (PMP) queries
- Secure patient record creation and prevention of identity fraud
- Verification of patient location at the time of telehealth services, where applicable
ID Verification Workflow at Navara Health
Primary Workflow
Upload via Jotform Intake
At the time of my initial intake, I will upload a clear photograph or scan of my government-issued photo ID through the Jotform intake link provided by Navara Health.
This is the standard workflow for all new patients, including telehealth patients.
Backup Workflow
In-Person at First Visit
If I do not upload my ID through the Jotform intake, my ID will be captured by Navara Health staff at my first in-person appointment.
I understand this is the backup workflow and may delay prescription or service processing until verification is complete.
Acceptable Forms of Identification
I will provide one or more of the following valid, unexpired forms of government-issued photo identification:
PrimaryU.S. State-issued driver's license
PrimaryU.S. State-issued identification card
PrimaryU.S. passport or passport card
AcceptableU.S. military ID
AcceptablePermanent Resident Card
AcceptableForeign passport (with U.S. address verification)
Additional secondary documentation (utility bill, lease agreement) may be requested in cases where primary ID and address do not match or for high-risk prescribing scenarios.
How My ID Information Will Be Used
I understand and agree that my ID information will be:
- Stored securely in my confidential medical record
- Used to verify my identity at appointments, for prescription processing, and for pharmacy coordination
- Used to satisfy Ryan Haight Act and DEA identity verification requirements for controlled substance prescribing (TRT)
- Used for PMP queries and other legally required identity confirmations
- Not shared with third parties outside of treatment, payment, or healthcare operations as described in the HIPAA Notice of Privacy Practices
- Protected under the same federal and state privacy laws that protect all of my Protected Health Information (PHI)
My Responsibilities
I agree that:
- The identification I provide is my own, valid, and unexpired
- I will update my ID on file if I obtain a new driver's license, ID card, or passport, or if my name or address changes
- I will not submit altered, fraudulent, expired, or borrowed identification
- I understand that misrepresenting my identity is grounds for immediate termination from the practice and may constitute a violation of federal and state law
- I will provide a clear, legible image if uploading; blurry or partial images may be rejected and re-requested
Consequences of Non-Verification
Failure to provide proper identification may delay or prevent:
- Prescription processing — including pharmacy orders for any medication
- Appointment scheduling or continuation of care
- Controlled substance prescribing (which has additional DEA verification requirements)
- Telehealth services
- Lab orders
For controlled substance therapy (such as TRT), prescriptions cannot be issued until identity verification is complete.
Patient Portal Access
I will receive an email from Navara Health with instructions on how to register for and create my secure patient portal login. The portal allows me to:
- Securely upload identity documentation (if not previously uploaded through Jotform)
- Access lab results and clinical notes
- Send and receive secure messages with my provider
- View and pay invoices
- Manage appointment scheduling
I am responsible for keeping my portal login secure and notifying Navara Health if I suspect unauthorized access.
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 or legally authorized to consent.
- I have read and understand this ID Verification Consent in its entirety.
- I understand the reasons identity verification is required and how my ID information will be used and protected.
- I will upload my government-issued photo ID through the Jotform intake link, or have it captured in person at my first in-clinic appointment.
- The identification I provide will be valid, unexpired, and my own.
- I will update my ID on file if it changes.
- I understand that misrepresenting my identity is grounds for immediate termination from the practice.
- I understand that failure to provide proper ID may delay or prevent prescriptions, appointments, and continuation of care.
- 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 Signature (or Typed Electronic Signature)
Type of ID Provided (DL / State ID / Passport / Other)
Verified By (Staff Signature)