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 an online application for clinical evaluation to determine whether a therapeutic device may be considered medically necessary for a documented health condition.

I understand that:

• This application 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 applications are conducted based solely on the information provided in this form.
• The provider retains full clinical discretion to approve or deny any request.
• This service is not a substitute for in person treatment/support, if needed.

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

It is your responsibility to confirm these requirements with your retailer and/or local authorities 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 telehealth 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 Texas 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 on the health information you voluntarily submit.

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

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 performed. This service is not a substitute for in-person medical care.

The information and documentation you receive are provided for informational and documentation purposes only. This service 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 responsible for consulting qualified professionals for those matters.

Your submission and the resulting documentation do not create a doctor patient relationship beyond this limited documentation service.

Licensing Jurisdiction

All services are rendered in the state of Texas for residents and purchases in Texas and Florida only.

For Texas patients, this service complies with 22 Tex. Admin. Code § 75.10. For Florida patients, services are provided under Dr. Morgan’s 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 originating in any other state.

No Guarantees

By submitting this form, you affirm that your request is voluntary and was not influenced by promises, guarantees, incentives, or coaching from any third party.

Our role is to provide documentation based on the information you submit and our clinical judgment. We do not guarantee acceptance, approval, reimbursement, savings, or any outcome related to tax authorities, insurers, government agencies, retailers, manufacturers, or any third party. All decisions made by third parties are outside our control.

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, interpreted, distributed, or presented.

Liability Release

By submitting this form, you agree to fully and irrevocably release and hold harmless Dr. Casey Morgan and West End Chiropractic from any and all liability related to this service and to any documentation created through this service. This release applies to the evaluation itself, the professional opinion provided, the written documentation that results, and all future use of that documentation without limitation to the fullest extent permitted by law.

This release applies to medical, legal, financial, administrative, or personal outcomes. It includes all issues related to licensing, jurisdiction, document formatting, signatures, acceptance or rejection by third parties, or any consequence that may result from your use or misuse of the service or the documentation at any time in the future. You assume full and permanent responsibility for all outcomes that follow this submission.

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 application, I affirm that I have:

• Read, understood, and agreed to all terms above
• Submitted this form truthfully, voluntarily, and without outside influence

I understand that all terms in this agreement are intended to be valid and enforceable under applicable law. If any individual term is found to be invalid, unlawful, or unenforceable, I agree that all remaining terms will continue in full force and effect without limitation. I certify under penalty of law that the information I provide is accurate and complete and that I accept full responsibility for this submission.