Waiver for Self-Reporting
Medicare & Medicaid Services

Purpose of This Waiver

This document is required when a patient who is a beneficiary of Medicare, Medicaid, TRICARE, or another federal healthcare program receives services at Navara Health, PLLC. It documents the patient's understanding that Navara Health is a self-pay practice, that services received here will not be billed to or reimbursable by these federal payers, and that the patient agrees not to submit claims for these services.

Navara Health — Non-Participating Status

Navara Health, PLLC and its providers, including Jessica Boggs, APRN and Simal Patel, MD, are not enrolled in and do not participate in:

• Medicare (including all parts and Medicare Advantage plans)
• Medicaid (Texas Medicaid and any other state Medicaid)
• TRICARE
• CHAMPVA
• Any other federal healthcare program

This means Navara Health does not bill, submit claims to, or accept payment from these programs for any service.

Statutory & Regulatory Basis

My Federal Payer Status

I confirm that I am a beneficiary of one or more of the following (check all that apply):

• ☐ Medicare Part A (Hospital)
• ☐ Medicare Part B (Medical)
• ☐ Medicare Part C (Medicare Advantage)
• ☐ Medicare Part D (Prescription Drug)
• ☐ Medicaid (state: ______________)
• ☐ TRICARE
• ☐ CHAMPVA
• ☐ Other federal healthcare program: ______________
• ☐ Dual eligible (Medicare and Medicaid)

Key Acknowledgments

Why Patients Choose Self-Pay Care at Navara Health

Patients may choose to receive care at Navara Health on a self-pay basis because:

• Many of the services offered (hormone optimization, peptides, GLP-1 for non-FDA-approved indications, aesthetic services, IV therapy, NAD+, sexual wellness) are not covered by Medicare or Medicaid regardless of provider
• They prefer the longer visits, integrative approach, and individualized care offered in a self-pay practice
• They prefer to keep certain services outside their insurance record
• They value the privacy and continuity that comes with a direct patient-provider relationship

Maintaining Federal Payer Coverage Elsewhere

This waiver applies only to services received at Navara Health. I understand that:

• I should continue to use my Medicare/Medicaid/other federal coverage for services received from in-network providers, hospitals, pharmacies, labs, and other facilities
• For any laboratory work ordered by Navara Health, I may choose either:
  • Self-pay through Navara Health's preferred lab (e.g., Rupa Health, Quest, LabCorp via direct-pay) — these results will not be submitted to Medicare/Medicaid
  • OR self-pay through a lab that accepts Medicare/Medicaid for that test — in which case Medicare/Medicaid may be billed by the lab directly, independently of Navara Health
• For prescription medications, I may use Medicare Part D / Medicaid Pharmacy benefits where the prescription is otherwise covered. Compounded medications and most off-label prescriptions from Navara Health are typically not covered.
• For emergency, hospital, or specialty care, I should continue to use my federal coverage

Duration of This Waiver

This waiver is effective from the date of signature and remains in force for the duration of my care at Navara Health while I remain a federal payer beneficiary. It will be re-affirmed annually as part of intake update. I may revoke this waiver at any time in writing, which will terminate my patient relationship with Navara Health (because federal payer enrollment is incompatible with continued service here).

Cooperation with Audit or Inquiry

If Medicare, Medicaid, or any federal payer makes inquiry regarding my care at Navara Health, I authorize Navara Health to provide a copy of this waiver as documentation that no federal payer was billed for services rendered.

Communication & HIPAA Authorization

I authorize Navara Health to communicate with me through patient portal, email, SMS, and telephone for billing and care coordination matters. I may revoke any channel in writing.

Dispute Resolution & Governing Law

Any dispute arising from this waiver shall be resolved by good-faith negotiation; if unresolved within 30 days, by binding arbitration in Dallas County, Texas. Parties waive jury trial. Governed by Texas law. Nothing in this waiver limits any rights that cannot be waived under federal law.