Please complete the following application to begin the review process. All submissions will be carefully evaluated to determine medical necessity. If appropriate, supporting documentation may 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 is an online documentation review to determine whether a therapeutic device may qualify as medically necessary for a documented health condition.

 

I understand:

• This is not tax, legal, or financial advice.
• This application does not guarantee approval or issuance of documentation.
• I must personally complete and submit this form. It may not be completed by a retailer, salesperson, or third party.
• This service is not intended for leisure, recreational, or general wellness use.
• All determinations are based solely on the information I provide.
• The provider retains full clinical discretion to approve or deny any request.
• This service is not a substitute for in person medical care if needed.

 

Retroactive prescriptions are not permitted.

 A valid prescription must be dated prior to purchase or delivery when required by regulatory guidelines. If a device has already been purchased or delivered, it may not qualify. Prescription dates will not 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.
• The provider’s role is limited to reviewing submitted materials and issuing documentation, if appropriate, based solely on professional clinical judgment.
• No outcomes, approvals, 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 any clinical recommendations deemed appropriate in my case. I understand that this consultation does not constitute legal, financial, or tax advice. I understand that all telehealth services take place in the state of Texas.

I have read the above consent and will contact the clinic with any questions regarding its content. By signing below, I agree to the above and acknowledge that this consent applies solely to this limited documentation-based evaluation and does not establish ongoing treatment, supervision, or clinical management beyond this submission.

TERMS OF SERVICE AND LIABILITY AGREEMENT

Independent Licensed Provider

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

1611 W. 5th St., Suite 110
Austin, Texas 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, vendor, manufacturer, or third party. Any purchases, services, delivery issues, or equipment matters are entirely separate from our office and outside the scope of this service.

Scope and Limitations

This service is based strictly on your self-reported health history. No physical examination, diagnostic imaging, or in-person testing has been performed. This service is not treatment and is not a substitute for in-person medical care.

The documentation provided is for informational and documentation purposes only. This service does not constitute legal, tax, accounting, or financial advice. You are responsible for consulting qualified professionals regarding those matters.

Submission of this form does not create an ongoing doctor-patient relationship beyond this limited documentation review.

Licensing Jurisdiction

All services are rendered in Texas. Submissions are accepted only for Texas and Florida residents and purchases.

Dr. Morgan is licensed in Texas. Texas services comply with 22 Tex. Admin. Code § 75.10.

Florida services are provided under Dr. Morgan’s Florida Telehealth Provider Certificate in accordance with Florida Statutes § 456.47 and Chapter 2019-137.

Submissions from any other state will not be accepted.

No Guarantees

You affirm your request is voluntary and not influenced by promises, incentives, guarantees, or coaching from any third party.

We do not guarantee approval, reimbursement, tax savings, acceptance by insurers, retailers, government agencies, or any other third party. All third-party decisions are outside our control.

Accuracy and Reliance

You certify that all information submitted is truthful, accurate, complete, and submitted personally by you.

This determination relies entirely on your statements. Inaccurate or incomplete information voids any documentation issued.

You accept full responsibility for how documentation is used, presented, interpreted, or distributed.

EXPRESS ASSUMPTION OF RISK AND RELEASE OF LIABILITY

TO THE FULLEST EXTENT PERMITTED BY TEXAS LAW, YOU RELEASE AND HOLD HARMLESS CASEY MORGAN, D.C., AND WEST END CHIROPRACTIC FROM ANY AND ALL CLAIMS, INCLUDING CLAIMS ARISING FROM ORDINARY NEGLIGENCE, RELATED TO:

• The evaluation process
• The professional opinion rendered
• The documentation created
• Any reliance on that documentation
• Any third-party rejection or acceptance
• Any medical, legal, financial, administrative, or personal outcome
• Any present or future use or misuse of the documentation

This release does not apply to gross negligence or willful misconduct.

Indemnification

You agree to indemnify and defend Casey Morgan, D.C., and West End Chiropractic against any claim arising from your use or misuse of this service or its documentation.

Electronic Signature Acknowledgment

By submitting this form, I agree that my electronic signature is legally binding and carries the same force and effect as a handwritten signature.

I acknowledge and accept the use of this electronic signature format for this agreement and any related documentation.

Self Pay Service and Insurance Non-Coverage

This service is provided on a self-pay basis and is not a covered benefit under insurance or Medicare.

Medicare coverage for chiropractic services is limited to manual manipulation of the spine to correct a subluxation. This documentation service is administrative in nature and is statutorily non-covered under Medicare guidelines. Because it is non-covered, no claim will be submitted to Medicare.

This service is also not covered by Medicaid, any commercial insurance plan, workers compensation, or any other third-party payer.

By submitting this form, you acknowledge and agree:

• This service is not covered by Medicare or any insurance plan
• No claim will be submitted to Medicare or any insurer
• No forms, invoices, or documentation will be sent to insurance
• No assistance will be provided for reimbursement, appeals, or coverage requests
• You are personally responsible for payment in full
• Insurance denial or non-coverage does not create a refund right or obligation

You elect to proceed with full knowledge that this is a non-covered, self-pay service and that no insurance submission or assistance will occur now or in the future.

Non-Refundable

All payments are final and non-refundable once the application is submitted for review.

Severability

If any provision of this agreement is found invalid or unenforceable, all remaining provisions remain in full force.

Electronic Signature

You agree your electronic submission and signature are legally binding under Texas law.

Acknowledgment

By submitting this application, you affirm:

• You have read and understood all terms
• You agree voluntarily
• You accept full responsibility for this submission