The rapid expansion of telehealth has fundamentally transformed how healthcare is delivered in the United States. What was once a niche service has become a cornerstone of modern medical practice, enabling providers to reach patients across vast distances and ensuring continuity of care for populations that might otherwise face significant barriers to access. However, this transformation has introduced a complex web of regulatory challenges that every provider and healthcare organization must navigate carefully.
At the heart of these challenges lies a deceptively simple question: Where is the patient located?
This question—seemingly straightforward—carries profound legal, operational, and financial implications for telehealth providers. The answer determines which state’s licensing requirements apply, which standards of care govern the interaction, what informed consent obligations must be met, and ultimately, whether the provider can legally deliver services at all. For multi-state telehealth operations, understanding this dynamic is not merely a compliance formality—it is the foundation upon which sustainable, legally sound practices are built.
For providers and healthcare organizations partnering with Hillcrest Medical Billing, this guide offers a comprehensive exploration of telehealth licensing by state, with particular focus on how patient location affects provider requirements. We will examine the regulatory landscape, explore the various pathways to multi-state practice, and provide actionable insights to help you build compliant, efficient telehealth operations.
Understanding the Legal Framework: Why Patient Location Matters
The State-Based Licensing System
The United States does not have a single, unified national medical licensing system. Instead, each state retains the authority to regulate the practice of medicine within its borders. This state-based approach means that a physician licensed in Texas is not automatically authorized to practice in California, and a nurse practitioner licensed in Florida cannot simply extend their practice into Georgia without meeting that state’s requirements.
The legal principle underlying this system is that the practice of medicine occurs where the patient is physically located at the time of the encounter. This principle applies regardless of whether the encounter is in-person or conducted via telehealth technologies. As the Center for Connected Health Policy (CCHP) has articulated, the practice of medicine—whether medical nutrition therapy, occupational therapy, or physician services—”occurs where the client is physically located at the time the telehealth technologies are used” .
This means that a provider sitting in their office in State A, conducting a video visit with a patient physically present in State B, is generally considered to be practicing medicine in State B. Consequently, the provider must comply with State B’s licensing requirements, standards of care, documentation rules, and prescribing regulations.
The Role of the Federal Government
While states hold primary authority over medical licensing, the federal government plays a limited but important role. Federal law permits interstate practice under specific circumstances, including:
- The Uniformed Services University of the Health Sciences and certain federal healthcare facilities
- The Veterans Health Administration, Indian Health Service, and Department of Defense providers
- The Sports Medicine Licensure Clarity Act, which protects sports medicine professionals licensed in their home state when providing services to athletes traveling in another state
- The Uniform Emergency Volunteer Health Practitioners Act, applicable during declared states of emergency in states that have enacted it
For the vast majority of civilian telehealth providers, however, state law governs licensure requirements. As the Department of Health and Human Services (HHS) has noted, “The ability to deliver health care services across state lines varies based on state regulations” .
The Traditional Pathway: Full Licensure in Each State
Requirements for Full Licensure
The most straightforward—and historically the most common—approach to multi-state telehealth practice is obtaining a full, unrestricted license in each state where the provider intends to serve patients. A full license granted by a state health care professional licensing board permits a provider to practice legally in that state, subject to all applicable laws and regulations .
The requirements for full licensure typically include:
- Educational verification: Confirmation that the provider completed an accredited educational program appropriate to their profession
- Examination scores: Documentation of passing required licensing examinations
- Background checks: Criminal background checks and review of any disciplinary history
- Fees: Application and licensing fees, which vary significantly by state
- Continuing education: Ongoing requirements to maintain the license in good standing
Maintenance of a full license requires annual or biennial renewal, payment of renewal fees, completion of continuing education requirements, and self-reporting of any disciplinary actions . For providers operating in multiple states, these administrative burdens multiply accordingly.
Advantages and Limitations
Full licensure offers several advantages. It provides the greatest operational flexibility, as the provider is not limited by the restrictions that may accompany temporary permits or telehealth registrations. Full licensure also typically allows the provider to establish an in-person presence in the state if desired, and it may facilitate participation in insurance networks and government payer programs that require in-state licensure.
However, the limitations are equally significant. The time and cost associated with obtaining and maintaining multiple full licenses can be substantial. For high-volume states like California and New York, which are not members of the Interstate Medical Licensure Compact, providers must apply for full licenses through each state’s individual medical board on the same timeline as any other license application . This can create significant operational delays for telehealth organizations planning national coverage.
Pathways to Multi-State Practice: Beyond Full Licensure
Recognizing the barriers that full licensure creates for telehealth expansion, many states have developed alternative pathways to facilitate cross-state practice. These pathways vary considerably in their scope, requirements, and limitations.
Temporary Practice Laws
Some states have enacted temporary practice laws to support continuity of care for patients who are temporarily located in another state. These laws typically allow a provider who has an existing relationship with a patient to continue providing care when the patient is visiting another state for a limited period.
This pathway is particularly relevant for providers treating transient populations—young adults attending college in another state, retirees who split their time between multiple states, or patients traveling for work or leisure . However, temporary practice laws vary widely in their duration limits, the types of providers eligible, and whether they apply to new patient relationships or only existing ones.
Licensure Reciprocity
Some states have reciprocity agreements that allow providers from another state to practice if certain conditions are met. These agreements are often regionally based, such as allowing providers from bordering states to serve patients near the state line. However, reciprocity arrangements are not universal, and the specific terms vary considerably from state to state .
Telehealth Registration
A growing number of states have established telehealth registration processes that allow out-of-state providers to practice telehealth within their borders without obtaining a full license. As of recent policy tracking, approximately 20 states have some form of telehealth registration process, though the terminology varies—some states call it a telemedicine license, others a registration, certification, permit, or waiver .
While the specifics differ by state, telehealth registration typically requires:
- A current, valid, and unrestricted license in another state
- No history of disciplinary proceedings
- Evidence of professional liability insurance
- Agreement not to open an office or provide in-person treatment in the state
- Annual registration and payment of a fee to the appropriate state licensing board
Florida provides a notable example of this approach. The state’s Out-of-State Telehealth Provider Registration process allows providers not licensed in Florida to register with the Florida Department of Health to provide telehealth services to Florida patients. Registered providers may not open an office or provide in-person healthcare services in the state .
Telehealth registration offers a middle ground between full licensure and temporary exceptions. It provides a streamlined pathway for out-of-state providers while preserving the state’s regulatory oversight and ensuring that providers remain subject to the state’s jurisdiction for disciplinary purposes.
Interstate Licensure Compacts
Interstate licensure compacts represent the most systematic approach to facilitating multi-state practice. These agreements among states allow providers to obtain expedited licensure or practice privileges in participating states, typically while maintaining their primary license in a home state.
Compacts are designed to preserve state oversight while reducing administrative barriers. As the CCHP has noted, compacts “seek to allow providers to meet only one approval process (through the Compact) to participate in multiple states, as long as they hold a license in good standing in their home state” .
The landscape of interstate compacts has expanded significantly in recent years. As of 2026, the major compacts relevant to telehealth include:
The Interstate Medical Licensure Compact (IMLC)
The IMLC provides a streamlined pathway for physicians to obtain licenses in multiple states. Physicians must meet specific eligibility requirements, including holding a full and unrestricted license in a compact state, possessing specialty certification, having no disciplinary history, and having completed an accredited graduate medical education program .
The IMLC operates somewhat differently from other compacts in that it focuses on expediting the licensure approval process with each state rather than issuing a single multistate license. Physicians receive individual licenses from each state they apply to through the compact process .
As of 2026, notable non-member states include California, New York, and Oregon. Physicians wishing to practice telehealth with patients in these states must apply for full licensure through the state’s individual medical board . Additionally, Hawaii and Vermont are compact members but are not eligible as States of Principal Licensure, meaning physicians cannot enter the compact through a Hawaii or Vermont license .
The Nurse Licensure Compact (NLC)
The NLC operates on a different model than the IMLC. Rather than issuing separate state licenses on an expedited basis, the NLC allows nurses who reside in a compact state to hold a single multistate license that is valid in all other compact states without additional applications or fees .
As of mid-2026, the NLC includes approximately 41 member states. The multistate license is issued by the nurse’s primary state of residence, not their state of employment. If a nurse moves to another compact state, they have 60 days to apply for a new multistate license in their new home state .
Notable non-compact states as of 2026 include California, New York, Illinois, and Michigan. Nurses providing telehealth services to patients in these states must hold individual licenses in each .
PSYPACT: The Psychology Interjurisdictional Compact
PSYPACT is widely regarded as one of the most telehealth-friendly licensing compacts. Rather than requiring separate state licenses, PSYPACT issues an Authority to Practice Interjurisdictional Telepsychology (APIT) that allows psychologists to practice telehealth into any PSYPACT member state without obtaining a separate license in that state .
As of 2026, PSYPACT covers more than 40 states, making it an exceptionally valuable pathway for behavioral health providers. Psychologists must hold a full, unrestricted license in a PSYPACT member state, have no history of disciplinary action, and meet education and supervised experience requirements to participate .
Other Compacts
Additional compacts relevant to telehealth providers include:
- The Counseling Compact, covering licensed professional counselors and licensed mental health counselors, with membership expanding significantly in 2025 and 2026
- The APRN Compact, allowing advanced practice registered nurses to practice across compact states, though it is newer and less widely implemented than the NLC
- The Physician Assistant Licensure Compact (PALC), following a model similar to the IMLC for physician assistants
- The Physical Therapy Compact, Occupational Therapy Compact, Social Work Licensure Compact, and others that address specific provider types
The proliferation of compacts reflects growing recognition among states that the traditional licensure model creates unnecessary barriers to telehealth access. However, the patchwork nature of compact membership means that providers must carefully verify which compacts apply to their profession and which states participate.
The Critical Importance of Patient Location Verification
Verifying Patient Location
Given the centrality of patient location to licensure requirements, establishing robust processes for verifying where the patient is physically located at the time of each telehealth encounter is essential. The HHS Telehealth website explicitly advises: “Prior to an appointment, providers should verify patient location and obtain consent” .
This verification serves multiple critical purposes:
- Licensure compliance: Confirming that the provider is licensed or otherwise authorized to practice in the state where the patient is located
- Standard of care determination: Identifying which state’s standards of care and practice requirements apply
- Prescribing authority: Ensuring compliance with state-specific prescribing rules, particularly for controlled substances
- Informed consent: Meeting the state’s specific requirements for patient disclosure and consent
- Documentation and billing: Ensuring accurate documentation and appropriate billing for the services rendered
Best practices for location verification include asking the patient to confirm their physical location at the beginning of each encounter, documenting the stated location in the medical record, and having policies in place for situations where the patient’s location is unclear or changes during the encounter.
Implications of Patient Location
The location of the patient at the time of the telehealth encounter has cascading implications for the provider’s obligations:
Licensure: As discussed, the provider must generally be licensed or authorized to practice in the state where the patient is located. Exceptions may apply through compacts, registrations, or temporary practice laws, but these must be carefully verified.
Standard of Care: State statutes define standards of care and malpractice in specific terms. Providers using telehealth must be aware of the standard of care in each state where they practice . While many states have determined that the standard of care for telehealth is the same as for in-person care, the specific articulation and application of these standards can vary. As the National Conference of State Legislatures has noted, “Standards of care for telehealth services are generally the same as those for in-person care, and several states took steps to enact them into legislation” .
Informed Consent: Forty-five states and the District of Columbia require providers to inform patients of the potential risks and benefits of telehealth usage . The specific requirements—whether verbal or written, what must be disclosed, and how consent must be documented—vary by state.
Patient-Provider Relationship: States differ in their requirements for establishing a patient-provider relationship through telehealth. While all 50 states allowed remote establishment of the patient-provider relationship during the COVID-19 pandemic, post-pandemic requirements are being reassessed, resulting in a varied regulatory landscape . Some states permit remote establishment, while others may require an initial in-person examination for certain purposes, such as prescribing controlled substances.
Prescribing: State laws governing prescribing via telehealth—particularly for controlled substances—vary considerably. Providers must understand the specific requirements in each state where they prescribe, including whether an in-person examination is required, what documentation must be maintained, and any restrictions on specific medications.
Standards of Care and Professional Obligations
The Standard of Care in Telehealth
A fundamental principle of telehealth regulation is that the standard of care is generally the same as for in-person care. As the Federation of State Medical Boards has articulated, providers must “maintain acceptable and appropriate standards of care” and adhere to the same professional ethics and scope of practice requirements regardless of the modality of care delivery .
This means that a physician conducting a telehealth visit is held to the same standard of care as a physician conducting an in-person visit. The specific requirements include:
- Proper evaluation and treatment: Including appropriate documentation, diagnostics, and clinical decision-making
- Establishment of the patient-provider relationship: Meeting the state’s requirements for forming a valid treatment relationship
- Informed consent: Obtaining and documenting patient consent in accordance with state requirements
- Continuity of care and referrals: Ensuring appropriate follow-up and referral practices
- Medical records: Maintaining accurate, complete, and confidential records
- Privacy and security: Complying with HIPAA and any additional state privacy requirements
Some states have taken steps to explicitly codify this equivalence. Idaho, Missouri, and Texas, among others, have determined that the standard of care for in-person services also applies to telehealth . However, the application of this standard can create complexities in telehealth contexts, as some have noted that “physicians may have an increased chance of misdiagnosis if they are unable to perform an in-person exam” . The legal fiction that telehealth care is equivalent to in-person care for standard of care purposes continues to evolve through legislation, regulation, and case law.
Documentation and Record-Keeping
Accurate documentation is essential in telehealth, both as a matter of clinical practice and as a legal requirement. Providers should document:
- The patient’s physical location at the time of the encounter
- The modality used (video, audio-only, store-and-forward)
- The provider’s location
- Verification of licensure or authorization to practice in the patient’s state
- Informed consent, including the method of obtaining and documenting consent
- The clinical encounter, including history, assessment, and plan
- Any limitations of the telehealth modality and how they were addressed
- Follow-up plans and referrals
Given the multi-state nature of telehealth practice, documentation systems must be capable of accommodating the varying requirements of different jurisdictions.
Operational Considerations for Multi-State Telehealth
Credentialing and Payer Enrollment
Licensure is only one component of the compliance landscape for telehealth providers. Even with appropriate licensure, providers must also consider credentialing requirements and payer enrollment. As the CCHP has noted, “compliance with state licensure and practice requirements doesn’t necessarily guarantee insurer coverage of services provided. Payer policies for out-of-state providers also vary” .
Commercial payers, Medicare, and Medicaid programs each have their own requirements for provider enrollment and reimbursement of telehealth services. These requirements may include:
- Enrollment in the payer’s network in the state where the patient is located
- Specific credentialing requirements
- Modifier and place-of-service code requirements for telehealth claims
- Documentation requirements specific to telehealth services
For organizations like Hillcrest Medical Billing, understanding these payer-specific requirements is essential to ensuring that providers receive appropriate reimbursement for telehealth services rendered across state lines.
Technology and Platform Considerations
The technology platforms used for telehealth must support compliance with state-specific requirements. This includes:
- Location verification: Systems that capture and document patient location
- Consent management: Tools for obtaining and documenting informed consent in accordance with state requirements
- Security and privacy: Compliance with HIPAA and any additional state-specific privacy requirements
- Documentation: Ability to maintain records that meet the requirements of multiple states
- Reporting: Capability to generate reports that support compliance monitoring and audit responses
Building a Compliance Framework
Given the complexity of multi-state telehealth regulation, a systematic compliance framework is essential. Key components include:
- Jurisdictional mapping: Identifying which states the organization intends to serve and understanding the licensing, standards of care, consent, and prescribing requirements for each
- Licensure strategy: Determining the most efficient pathway to multi-state authorization, whether through compacts, registrations, or full licensure
- Policy and procedure development: Creating policies that address location verification, consent, documentation, and other compliance obligations
- Training and education: Ensuring that providers and staff understand their obligations and the specific requirements of each jurisdiction
- Monitoring and auditing: Regularly reviewing compliance with state requirements and updating policies as regulations change
- Payer contracting: Ensuring that the organization has appropriate contracts and enrollments with payers in each state where services are provided
The Evolving Regulatory Landscape
Post-Pandemic Changes
The COVID-19 pandemic prompted unprecedented flexibility in telehealth regulation. All 50 states allowed patient-provider relationships to be established remotely for prescribing medications, and many states relaxed or waived licensure requirements to facilitate cross-state telehealth .
Post-pandemic, states are reassessing these flexibilities. The result has been a varied regulatory landscape in which some states have made permanent changes to facilitate telehealth, while others have reverted to pre-pandemic requirements or adopted new restrictions . This dynamic environment requires ongoing attention to regulatory developments in each state where an organization operates.
Trends in State Regulation
Several trends are shaping the future of telehealth regulation:
Compact Expansion: Interstate compacts continue to expand, with new states joining existing compacts and new compacts being developed for additional provider types. This trend toward greater portability of licensure is likely to continue.
Telehealth Registration Growth: More states are establishing telehealth registration processes as a middle ground between full licensure and unrestricted practice. These processes offer a streamlined pathway while preserving state oversight.
Standard of Care Clarification: States are increasingly clarifying that the standard of care for telehealth is equivalent to in-person care, while also developing specific guidance for telehealth practice.
Prescribing Regulations: State laws governing prescribing via telehealth, particularly for controlled substances, continue to evolve. Providers should expect ongoing changes in this area.
Payer Policy Alignment: As telehealth becomes a permanent fixture in healthcare delivery, payers are refining their policies for coverage and reimbursement of telehealth services, including requirements for out-of-state providers.
How Hillcrest Medical Billing Supports Multi-State Telehealth Providers
Navigating the complex landscape of telehealth licensing, credentialing, and payer requirements requires specialized expertise. Hillcrest Medical Billing offers comprehensive support to healthcare organizations seeking to build and maintain compliant multi-state telehealth operations.
Our services include:
- Credentialing and enrollment support: Assistance with payer enrollment and credentialing in multiple states, ensuring that providers meet the requirements of each payer and jurisdiction
- Revenue cycle management: End-to-end billing and collections services that account for the unique requirements of telehealth claims, including appropriate modifiers, place-of-service codes, and documentation
- Compliance guidance: Support in understanding and meeting the licensure, consent, documentation, and prescribing requirements of each state
- Denial management: Expert handling of telehealth claim denials, including those related to licensure or enrollment issues
- Reporting and analytics: Tools and insights to monitor revenue cycle performance and identify opportunities for improvement
With experience serving providers across multiple states and payer types, Hillcrest Medical Billing understands the operational and compliance challenges that multi-state telehealth creates. Our team is equipped to help your organization navigate these complexities so that you can focus on delivering quality patient care.
Conclusion: Patient Location as the Compass for Telehealth Compliance
The question of where the patient is located is not merely a logistical detail in telehealth—it is the compass that guides the entire compliance framework. From licensure and credentialing to standards of care and prescribing authority, the patient’s physical location at the time of the encounter determines which state’s laws apply and what obligations the provider must fulfill.
For telehealth providers and organizations, success in this environment requires:
- A clear understanding of the state-based licensure system and the principle that practice occurs where the patient is located
- A strategic approach to obtaining and maintaining authorization to practice across state lines, whether through full licensure, telehealth registration, or interstate compacts
- Robust operational processes for verifying patient location, obtaining consent, documenting encounters, and complying with state-specific requirements
- Ongoing monitoring of regulatory developments, as the telehealth landscape continues to evolve
- Expert support in navigating the credentialing, billing, and compliance complexities that multi-state practice entails
As telehealth continues to transform healthcare delivery, the organizations that thrive will be those that build compliance into their operations from the ground up. By understanding how patient location affects provider requirements and implementing systems to address those requirements, telehealth providers can deliver care with confidence—knowing that they are meeting their legal and professional obligations while serving patients wherever they may be.
For providers seeking support in navigating these complexities, Hillcrest Medical Billing stands ready to assist. Our expertise in credentialing, revenue cycle management, and compliance for telehealth providers can help your organization build a sustainable, compliant multi-state practice.
About Hillcrest Medical Billing
Hillcrest Medical Billing provides comprehensive medical billing, credentialing, and revenue cycle management services to healthcare providers and organizations. With expertise spanning multiple specialties and payer types, we help providers optimize their revenue while maintaining compliance with the complex regulatory requirements of modern healthcare. For more information about how we can support your telehealth practice, contact our team today.