Asynchronous Telehealth: Which States Let It Start a Patient Relationship

"Asynchronous" covers several things: a patient uploads photos and a history for a dermatologist to review, a primary care physician sends images to a specialist, a weight-loss program reviews intake answers and labs before deciding whether to treat. Most states permit some form of it. The legal fault line is narrower and more important: can an asynchronous exchange, with no live interaction, establish a new provider-patient relationship? That is the step an async-first business model depends on.

Which states expressly allow async care to establish a relationship?

From the statutes and rules we have verified:

• California. The prior examination required before prescribing "does not require a synchronous interaction" and may use a self-screening tool or questionnaire, provided the standard of care is met (Cal. Bus. & Prof. Code § 2242(a)).
• Delaware. A relationship may be established in person or by telehealth, synchronous or asynchronous store and forward, if the provider can meet the in-person standard of care, with location and identity verification, informed consent, a diagnosis, follow-up coverage and a written visit summary (24 Del. C. § 6003).
• Florida. Telehealth means synchronous or asynchronous technology, excluding only email and fax, and an evaluation sufficient to diagnose and treat needs no prior history review or physical exam (Fla. Stat. § 456.47(1)(a), (2)(b)).
• Maryland. A practitioner may establish a relationship through synchronous or asynchronous telehealth after verifying identity, disclosing name, contact information and license type, and obtaining consent (Md. Code, Health Occ. § 1-1002).
• Minnesota. Telehealth, which includes store-and-forward, may establish a physician-patient relationship (Minn. Stat. § 147.033; § 62A.673).
• Ohio. Medical Board rules allow synchronous or asynchronous technology where the in-person standard of care can be met (Ohio Admin. Code 4731-37-01).
• Oregon. Physicians and PAs may establish a relationship, diagnose and prescribe by telemedicine, defined to include synchronous and asynchronous technology (Or. Rev. Stat. § 677.494).
• Tennessee. The relationship may be established using secure video or store-and-forward (Tenn. Comp. R. & Regs. 0880-02-.14(7)).

Which states allow it only with specific clinical inputs?

• Texas. Tex. Occ. Code § 111.005(a)(3)(B) accepts asynchronous store and forward technology, alone or with synchronous audio, as long as the practitioner uses clinically relevant photographic or video images, including diagnostic images, or the patient's relevant clinical records such as history, lab and pathology results and prescription history. The practitioner must give follow-up guidance and, with consent, send a report to the patient's primary care physician within 72 hours.
• North Dakota. A relationship may be established entirely by telemedicine if the exam is equivalent to an in-person exam, such as secure video or store-and-forward with the necessary peripherals. A static online questionnaire does not qualify (N.D. Cent. Code § 43-17-44).
• Connecticut. Telehealth may be delivered by real-time two-way communication or store and forward, with access to or knowledge of the patient's medical history and health record (Conn. Gen. Stat. § 19a-906). Texting and email do not count.

Which states require a real-time interaction first?

• Mississippi. Board of Medical Licensure rules say store-and-forward may supplement but never replace real-time interaction (30 Miss. Admin. Code pt. 2635, R. 5.5). An async-only start does not fit.
• Rhode Island. The board's rule treats asynchronous evaluation without a contemporaneous, real-time interactive exchange as inappropriate (216-RICR-40-05-1, § 1.5.9).
• South Dakota. Before diagnosis and treatment, the clinician must provide a face-to-face exam using real-time audio and video whenever an in-person encounter would be required for the same service (S.D. Codified Laws § 34-52-3). That rules out async starts for most visits.

What do states say about patient-generated forms?

Many states that permit store-and-forward still separate it from a form the patient fills in. Arkansas's Medical Board says an online medical history forwarded to a physician is not store-and-forward and does not create a relationship (Ark. Code Ann. § 17-80-402). Alaska, Delaware, Kentucky, Maine, Maryland, Hawaii, Idaho and others prohibit prescribing based on an internet questionnaire alone. Massachusetts goes the other way in its definition: its telehealth statute includes "online adaptive interviews" (Mass. Gen. Laws ch. 112, § 5O), though prescribing still requires an adequate history and exam. The full comparison is in where prescribing from a questionnaire alone is prohibited.

Does async work for controlled substances?

No. DEA's temporary telemedicine rule (90 FR 61301, through December 31, 2026) requires an interactive telecommunications system under 42 CFR 410.78(a)(3), which is real-time audio-video, with audio-only in narrow cases. The proposed special registration rule would also require audio-video. Async is for non-controlled care. See what changes on January 1, 2027.

Does Medicare pay for asynchronous telehealth?

Under Social Security Act § 1834(m)(1), Medicare allows asynchronous store-and-forward as telehealth only in federal telemedicine demonstration programs in Alaska and Hawaii. Elsewhere, Medicare pays for some asynchronous work through separate codes rather than as telehealth. The broader Medicare picture is on our Medicare telehealth hub. Medicaid coverage of store-and-forward varies by state; see Medicaid telehealth coverage.

How should an async service line be built across states?

1. Sort your states into three groups: async start allowed, async start allowed with defined inputs, and real-time first. Route patients from the third group to a video visit.
2. Collect the inputs the strict states name. Photos for dermatology, labs for weight management, records for chronic conditions. Texas's list is a good default everywhere.
3. Keep the clinician's escalation path open. Every async review should be able to convert to video, order labs or decline.
4. Verify identity and location before review and record both. See patient location verification.
5. Write the follow-up plan into the response. Texas and Delaware require one, and it is good practice everywhere.

Our asynchronous teledermatology post applies this to one service line. The 50-State Telehealth Matrix ($2,950 for one service line) sorts every state into those groups with citations, for your counsel to review; state-level detail is in the telehealth law index.