Establishing a Patient Relationship by Telehealth

The old rule was that a physician-patient relationship began with a handshake and an exam. A decade of state legislation and board rulemaking has replaced it with a list of conditions that a video visit, and sometimes an audio call or an asynchronous review, can satisfy. Most states now say some version of the same thing: a relationship may be established by telehealth if the clinician can meet the same standard of care as in person. The differences are in the conditions attached, and those decide how a first visit must be built.

What does almost every state require at the first visit?

Read across the statutes and board rules in our telehealth law index, the same elements recur. Delaware's statute (24 Del. C. § 6003(a)) is the most complete list, and Indiana (Ind. Code § 25-1-9.5-7), South Dakota (S.D. Codified Laws § 34-52-3), Mississippi (Miss. Code Ann. § 41-127-1) and Colorado Medical Board policy track it closely:

1. Identity and location of the patient, verified. Colorado's board policy says no relationship exists if either party's identity is unknown. Oklahoma, Ohio, Tennessee and others require the patient's location to be confirmed. See verifying where the patient is.
2. Identity and credentials of the clinician, disclosed. Maryland requires name, contact information and license type (Md. Code, Health Occ. § 1-1002); Connecticut requires a license number and contact information (Conn. Gen. Stat. § 19a-906).
3. Consent after disclosure of how telehealth works and its limits. See what a consent form must cover.
4. A history and an exam appropriate to the condition, sufficient for a diagnosis. Maine's joint rule requires a history and exam sufficient for an informed diagnosis before treating or prescribing.
5. A diagnosis and a discussion of treatment options, risks and benefits.
6. Follow-up coverage: the clinician or a colleague available afterward. Idaho requires the provider, or a group colleague, to be available for follow-up (Idaho Code § 54-5706).
7. A record, and in Delaware and Indiana a visit summary given to the patient.

A first-visit template that captures all seven, with the patient's state recorded, satisfies the structural requirements in every state we have reviewed. The harder questions are about modality.

Can an audio-only call establish a relationship?

The states split clearly:

• Yes, where the standard of care is met: Florida, Kansas, Mississippi, Montana, Nevada, Ohio (only when every element of a bona fide visit is performed by phone), Arkansas (for a provider with access to the patient's health record), West Virginia (where the call meets the standard of care), and Minnesota for scheduled audio-only visits through June 30, 2027 (Minn. Stat. § 62A.673).
• No: Maryland's definition of telehealth excludes care delivered solely by audio-only calls (§ 1-1001); New Jersey excludes audio-only calls used alone from telemedicine (N.J. Stat. Ann. § 45:1-61); Tennessee's board definition excludes audio-only; North Dakota says an audio conversation alone does not meet the standard of care (N.D. Cent. Code § 43-17-44); South Dakota requires real-time audio and video wherever an in-person encounter would be required (§ 34-52-3); Iowa prohibits prescribing based solely on a telephone evaluation without a valid relationship.
• Conditionally: Arizona and Delaware count audio-only as telehealth only when video is not available to the patient (A.R.S. § 36-3601; 24 Del. C. § 6001(6)). Louisiana allows audio without video if, after reviewing records, the clinician can meet the in-person standard.

Controlled substances add a federal layer. DEA's temporary rule (90 FR 61301, through December 31, 2026) allows audio-only only where 42 CFR 410.78(a)(3) does. See audio-only telehealth rules.

Can an asynchronous exchange establish one?

Many states say yes, including California, Delaware, Florida, Kansas, Maryland, Minnesota, Nebraska, New Hampshire, Ohio, Oregon, Tennessee, Utah, Washington and Texas (with clinical images or records). Mississippi, Rhode Island, South Dakota and West Virginia (outside pathology and radiology) require a real-time exchange. The detail is in asynchronous telehealth by state, and the related question of intake forms is in where prescribing from a questionnaire alone is prohibited.

Which states require an in-person visit later?

A relationship formed by telehealth is not always allowed to stay that way:

• Alabama. If the same condition is treated by telehealth more than four times in 12 months without resolution, the patient must be seen in person or referred within 12 months; mental health services are exempt (Ala. Code § 34-24-704). The count runs across the physician or practice group, so rotating clinicians does not reset it.
• Georgia. Medical Board rules require diligent efforts to have the patient seen in person at least annually (Ga. Comp. R. & Regs. 360-3-.07).
• Controlled substance rules in Alabama, Louisiana, Hawaii (for opiates) and Rhode Island tie prescribing to an in-person visit, and Minnesota requires a prior in-person exam for many controlled substances and some other drugs (Minn. Stat. § 151.37).

Are there profession or patient-specific rules?

• Minors in Tennessee. Board rules require a facilitator to be present for patients under 18 (Tenn. Comp. R. & Regs. 0880-02-.16).
• Peripherals in Georgia. Without a prior in-person exam by a Georgia licensee, the physician must be able to examine the patient with technology and peripherals equal or superior to an in-person exam.
• New Mexico allows treatment of a new patient during a face-to-face videoconference if the clinician takes a history, obtains informed consent, keeps a record, and records or appropriately waives a physical exam (16.10.8.8 NMAC).
• Texas requires guidance on follow-up care and, with consent, a report to the patient's primary care physician within 72 hours for relationships formed under § 111.005(a)(3).

What is the federal picture?

For non-controlled care, the relationship is a state question. For controlled substances, the Ryan Haight Act's in-person evaluation requirement (21 U.S.C. 829(e)) is suspended only through December 31, 2026 by DEA's temporary rule, and a relationship formed by video does not by itself satisfy the federal rule after that unless a final special registration rule or another extension is in effect. See the Ryan Haight Act's in-person exam rule.

How should a practice design the first visit?

1. Default to real-time video for every new patient. It meets the modality rules in nearly every state we have reviewed; Georgia's peripheral requirement for patients not examined in person is the main exception.
2. Build the seven elements into a required first-visit template with the patient's state captured at check-in.
3. Allow audio-only or async starts only in states on the permitted list for that modality, and only for service lines where the standard of care supports it.
4. Track state-specific later obligations: Alabama visit counts, Georgia annual efforts, Texas PCP reports.
5. Recheck the list each year. These rules change more often than licensing statutes.

Our 50-State Telehealth Matrix ($2,950 for one service line) maps relationship, modality and in-person rules for every state, and the Telehealth Launch Blueprint ($4,950, up to five states) builds the first-visit workflow around them. Both are research for your counsel to review, not legal advice.