Please complete the following application to begin the review process. All submissions will be carefully evaluated to determine medical necessity. If appropriate, supporting documentation will be provided. This process ensures compliance with applicable standards and is not a guarantee of approval.

Service provided by:

West End Chiropractic in Austin, TX.

By submitting this request, I affirm that all information provided is accurate, truthful, and complete to the best of my knowledge. I understand this submission is a request for clinical evaluation to determine whether a therapeutic device may be considered medically necessary for a documented health condition.

I understand that:

• This request does not guarantee approval or issuance of a prescription.
• This service is not intended for leisure, recreational, or general wellness purposes, and should not be used as such.
• All reviews are conducted based solely on the information I provide.
• The provider retains full clinical discretion to approve or deny any request.

Retroactive Prescriptions Are Not Permitted
Most regulatory guidelines require a valid prescription to be dated prior to purchase or delivery. If the device has already been obtained, it may not qualify.

It is your responsibility to confirm these requirements with my retailer before purchasing or accepting delivery. Prescription dates cannot be backdated under any circumstance.

By continuing, I acknowledge:

• I accept full responsibility for the accuracy of my submission
• I have not been coached or promised specific results or incentives by any third party
• I agree to hold the reviewing provider and practice harmless for any legal, financial, or regulatory consequences that may result from this service, including but not limited to: denials of submission, improper submission, or false, incomplete, or misleading information
• The provider’s role is limited to reviewing submitted material and, if appropriate, issuing documentation based solely on professional clinical judgment
• No outcomes, benefits, or financial savings are guaranteed

HIPAA, LICENSE & NOTICE TO PUBLIC

We follow all current HIPAA guidelines to protect your privacy and health information. For the most up-to-date compliance details, please see our linked HIPAA, Privacy Policy, License & Mandatory Notice to the Public

I hereby request and consent to the performance of a chiropractic evaluation, telecommunication (including, but not limited to phone calls, SMS text, e-mails, and voicemails) and/or any clinical services/recommendations that are deemed necessary in my case. I further understand that this consultation and examination does not serve or hold itself out to be legal or tax advice. I further understand that all telemedicine services take place in the state of Texas.

I have read the above consent and I will contact the clinic to ask questions regarding its content. By signing below, I agree to the above and intend this consent to cover my entire course of evaluation and/or treatment for my present condition and for any future condition(s) for which I seek treatment/consultations with this office.

By submitting this form, you acknowledge and agree to the following:

Independent, Licensed Provider

This evaluation is conducted by Dr. Casey Morgan, D.C., a licensed chiropractor operating through West End Chiropractic, located at:

1611 W. 5th St., Suite 110, Austin, TX 78703.

We are a standalone healthcare provider, offering documentation services based solely on the health information you voluntarily submit.

We are not affiliated with, employed by, or financially connected to any hot tub company, retailer, or third-party service. Any purchases, services, or experiences involving equipment or retailers are completely separate from our office and fall outside the scope of our clinical review.

Scope and Limitations

This service is based strictly on your self-reported health history. No physical exam, diagnostic imaging, or in-person testing has been conducted. It is not a substitute for in-person medical care and should be viewed as a documentation service only.

The information provided through this service is intended for informational and documentation purposes only. It does not constitute medical treatment or legal, tax, or financial advice. Dr. Morgan and his representatives are not attorneys, accountants, or financial advisors. You are encouraged to consult qualified professionals for those matters.

Licensing Jurisdiction

All services are rendered in the state of Texas for residents and/or purchases made in Texas and/or Florida ONLY.

For Texas patients, this service complies with all applicable standards under 22 Tex. Admin. Code § 75.10. For Florida patients, services are provided under Dr. Morgan’s active Florida Telehealth Provider Certificate, in accordance with Florida Statutes § 456.47 and Chapter 2019-137.

We are not licensed or credentialed to provide services outside of Texas or Florida, and do not accept submissions from residents or purchases from other states.

No Guarantees

By submitting this form, you affirm that:

You affirm that no third party influenced your decision by offering promises, guarantees, or incentives. This request was made voluntarily, without coaching or expectation of a specific outcome.

Our role is to provide documentation based on the information you submit and our clinical judgment. We do not control, guarantee, or make representations about whether any state agency, tax authority, insurer, or third party will accept or honor the documentation provided. We do not guarantee approval, savings, or any specific outcome.

Accuracy and Integrity

You affirm that the information you provide is truthful, accurate, and complete to the best of your knowledge. You agree to use any documentation lawfully and appropriately, and accept full responsibility for how it is applied or presented.

Liability Release

By submitting this form, you agree to hold harmless and release Dr. Casey Morgan and West End Chiropractic from any and all liability related to the use or misuse of the information provided through this service.

Non-Refundable Submission

All payments are final and non-refundable. Once your application is submitted for review, no refunds will be issued, regardless of outcome.

Signature Acknowledgment

By submitting this form, I affirm that I have:

• Read, understood, and agreed to all terms above
• Consented to receive telehealth documentation services under Texas and/or Florida regulations
• Submitted this form truthfully, voluntarily, and without outside influence