Since the spring of 2020, state regulators granted temporary waivers which allowed patients to have telemedicine visits with out-of-state providers, even if those providers were not licensed in the state where the patient was located.

Well over half of US states and nearly all of Penn Medicine’s surrounding states have now ended state licensure waivers associated with the Covid-19 public health emergency.

Additionally, there is increasing attention from state medical boards on out-of-state telemedicine activity, including enforcement of laws requiring a clinician to be licensed in the state where the patient originates the telemedicine visit. This means that even activities such as telemedicine return patient visits, which may have been considered low risk to perform across state lines without obtaining additional licenses pre-pandemic, are now under increased scrutiny.

For the reasons stated above, Penn Medicine’s Office of General Counsel has advised that practicing telemedicine, including RPVs, across state lines without a license is not advised and poses a risk to the clinician. Penalties for unauthorized/unlicensed practice vary by state.

Below is a list of FAQs, guidance on the licensure application process for six states with the greatest share of Penn Medicine’s telemedicine patients, a list of states with exceptions to this general out-of-state telemedicine licensing rule, and other strategies to consider.

Please email PennConnectedHealth@uphs.upenn.edu with any questions, and please consult OGC if you have a need to prescribe controlled substances as a part of these telemedicine visits.

• Link to application: https://newjersey.mylicense.com/eGov/Login.aspx?ReturnUrl=%2feGov%2f
• License application guidance:
  • Select “Register a person” in the menu on the left-hand side of the screen to create an account. Scroll to the bottom of the screen and enter your last name, SSN, and DOB under “Other Registration” then click “Search”. Fill out all requested information on subsequent page and click “Register”.
  • After registration, you will be logged out. Login with your new credentials. Once logged in, select “Initial Application” from the left-hand menu. When prompted to “Select profession”, physicians should select “Medical Examiner” from the dropdown.
• [Only if necessary to prescribe controlled substances] – CDS Registration:
  • Pennsylvania-licensed providers with Pennsylvania DEA registration can apply for NJ CDS with the Pennsylvania office location on the registration form. Office address used must be the same address used on DEA registration.
  • Please be aware that NJ patients will need to initially and periodically come to Pennsylvania for in-person visits for refills of certain scheduled drugs to be compliant with the CDS laws.
  • Step 1: Complete the appropriate CDS initial or reinstatement application, including the attestation, found at https://www.njconsumeraffairs.gov/dcu/Pages/applications.aspx which is PDF fillable. If the application you are completing requires notarization, the application must be notarized. If your application is for an additional/branch location, please notate such (e.g. "branch") at the top of your application.
  • Step 2: Submit the completed application and attestation together in one email to CDS@dca.njoag.gov
  • Address of Record: Please be advised, the CDS application is under revision and a New Jersey address is not required as currently indicated on the application. The applicants CDS address of record must be the same as their primary license address of record. For example, an out of state physician (no practice location in NJ) must use their Board of Medical Examiners address of record as their CDS address of record.
  • Application Fee: Once your CDS registration is issued, you will receive an invoice via email, which will include instructions for paying by debit card, credit card, check, or money order.
  • Federal DEA: Upon issuance of your CDS registration, you are required to obtain a federal DEA registration. You will receive additional information about this once your CDS registration has been issued. Your home state DEA registration is acceptable so long as the address associated corresponds with the address you use when applying for a CDS registration. For DEA registration questions please contact the DEA Registration Unit at 1-(888) 356-1071, DEA.Registration.Help@usdoj.gov, and/or visit https://www.deadiversion.usdoj.gov/drugreg/index.html.
  • For Schedule II drugs, NJ requirements are more restrictive than the Federal requirements. An in-person examination of the patient is required for the initial prescription and every 90 days thereafter.
  • Prescribers are required to access the NJPMP for a patient: The first time they prescribe any Schedule II medication or opioid for acute or chronic pain, or a Schedule III or IV benzodiazepine; Every 3 months thereafter, if continuing to prescribe one of the above; and any time the patient appears to be seeking CDS for any purpose other than the treatment of an existing medical condition (e.g., misuse, abuse, or diversion).
• Request a CHCA leasing agreement:
  • Add physician to the appropriate tab on the NJ License & CHCA Lease Tracker SharePoint
  • Submit request to Joi Little from OGC (joi.little@pennmedicine.upenn.edu) by email
  • OGC will return a prepared document for the physician to sign
• Associated costs:
  • Application fee: $325 (at the time of application – personal checks not accepted)
  • License endorsement fee: $225 (at the time of licensure – personal checks not accepted)
  • License registration fee: $290 (per year)
  • NJ CDS fee (only if prescribing CDS): $40 (at the time of issuance)
  • Total cost: $550-590 (one-time) + $290 annually
• Contact information: New Jersey Division of Consumer Affairs, 973-424-8150 (Option 3)
• Definition of telemedicine:
  • Medicaid: Telemedicine means the delivery of a health care service using electronic communications, information technology, or other electronic or technological means to bridge the gap between a health care provider who is located at a distant site and a patient who is located at an originating site, either with or without the assistance of an intervening health care provider. Telemedicine does not include the use, in isolation, of audio-only telephone conversation, electronic mail, instant messaging, phone text or facsimile transmission. SOURCE: NJ Statute C.30:4D-6K(e) – cites: NJ Statute C.45:1-61. (Accessed Jul. 2021).
  • Private Payers: Telemedicine means the delivery of a health care service using electronic communications, information technology, or other electronic or technological means to bridge the gap between a health care provider who is located at a distant site and a patient who is located at an originating site, either with or without the assistance of an intervening health care provider. Telemedicine does not include the use, in isolation, of audio-only telephone conversation, electronic mail, instant messaging, phone text or facsimile transmission. SOURCE: NJ Statute C.26:2S-29(e). (Accessed Feb. 2021).

• Application Qualifications:
  • You may apply for an Interstate Telehealth Registration only if you are licensed in a state other than Delaware and your license is in good standing.
  • This will enable you to have new and return telehealth visits, with patients located in Delaware.
    • Note: The website outlines that the registration only permits telehealth if a health-care provider-patient relationship has been established. The provider-patient relationship can be established via the initial telehealth visit. Penn Medicine's standard operating procedures for telehealth meet these requirements.
• Link to application: https://delpros.delaware.gov/OH_HomePage
• License application guidance:
  • Click GO on the Apply/Manage a License and Service Requests tile.
    • If you do not have a DELPROS user account, click the REGISTER button on the left side of page for NEW USERS.
    • If you already have a DELPROS user account, enter your email address and password on the right side for EXISTING USERS and click the LOGIN button.
  • DELPROS allows you to save your incomplete application and return to it later to finish the process. You only have six (6) months to submit your application once you begin. If you do not submit your application within six months of starting it, you will be required to restart the entire online application again.
  • You may check the status of your application online throughout the entire application process by using the "View Application Status" feature in DELPROS on your e-License dashboard.
  • List of requirements here. FAQs here.
• Requirements for Interstate Telehealth Registration:
  • You are required to submit a verification during your application process. A self-query from the National Practitioner Data Bank (NPDB) can be found at www.npdb.hrsa.gov. The self-query report will be mailed to your address. When you receive the report, mail (do not fax) the original report to the Board office OR upload the report directly to your application.
• Associated costs:
  • Application fee: $50
  • License verification fee: $17
  • NPDB self-query fee: $3
  • Background check: $65
  • Total cost: $135
• Expected timeline:
  • Depends on the volume of applications, but usually 6-8 weeks after submission
• Contact information: Delaware Division of Professional Regulation, customerservice.dpr@delaware.gov
  • Telephone – (302) 744-4500, Monday – Friday, 8:15 a.m. – 4:15 p.m. Closed on State Holidays.
• Links for additional Delaware interstate telehealth registration for other providers:
  • Physician Assistant: Medical Interstate Telehealth Registration-PA
  • Nursing: Nursing Interstate Telehealth Registration
  • Social Worker: Social Work Examiners Interstate Telehealth Registration
  • Psychologist: Psychologist Interstate Telehealth Registration
  • Mental Health: Mental Health Interstate Telehealth Registration
  • Other: Medical Interstate Telehealth Registration-Other
    • “Other” includes: Certified Midwife, Certified Professional Midwife, Poloysomnographer, Respiratory Practitioner, Acupuncture Practitioner, Acupuncture Detoxification Specialist, Eastern Medicine Practitioner, Genetic Counselor.
• Definition of telemedicine:
  • Medicaid: Telemedicine is a cost-effective alternate to face-to-face encounters where access to care is compromised due to the lack of available service providers in the patient’s geographical location. This definition is modeled on Medicare’s definition for telehealth services located at 42 CFR Sec. 410.78. Note that the Federal Medicaid statute does not recognize telemedicine as a distinct service. For purposes of DMAP, telemedicine is the use of medical or behavioral health information exchanged from one site to another site via an electronic interactive (two-way, real time) telecommunications system to improve a patient’s health. SOURCE: DE Medical Assistance Program. Practitioner Provider Specific Manual, 5/20/21. Ch. 16 Telemedicine, 16.1 & 16.2 (Accessed July 2021).
  • Private Payers: “Telemedicine” means a form, or subset, of telehealth, which includes the delivery of clinical health-care services by means of real time 2-way audio (including audio-only conversations, if the patient is not able to access the appropriate broadband service or other technology necessary to establish an audio and visual connection), visual, or other telecommunications or electronic communications, including the application of secure video conferencing or store and forward transfer technology to provide or support health-care delivery, which facilitates the assessment, diagnosis, consultation, treatment, education, care management and self-management of a patient’s health care.” SOURCE: Title 24 Chapter 60 (2022 Delaware code).

• Link to application: https://www.flhealthsource.gov/telehealth/files/application-telehealth-provider-registration.pdf
• Registration application guidance:
  • Pennsylvania physicians:
    • Complete license verification with Pennsylvania Licensing System (PALS)
    • Note: they will send directly to Florida medical board
    • Complete an out-of-state telemedicine provider registration (no license required) (see sample completed with Penn Medicine info)
    • For item 8 on the above application form, fill out the following information for your Registered Agent:
      • Name: CT Corporation System
      • Address: 1200 South Pine Island Road, Plantation, FL 33324
    • Email completed forms to Email: MQA.Telehealth@flhealth.gov
  • New Jersey physicians:
    • Print, complete, and mail above application form to the following address along with a $50 certified check or money order payable to "State of NJ, BME"
      • State Board of Medical Examiners
      • Document Management Unit
      • P.O. Box 183
      • Trenton, NJ 08625-0183
    • NJ will mail your license verification to FL
    • Note: You may complete and submit your Florida Telehealth Registration Application prior to the verification being completed; FL will approve once received
  • FAQs
• Associated costs:
  • Pennsylvania license certification: $15
  • New Jersey license certification: $50
• Contact information: Florida Department of Health, MQA.Telehealth@flhealth.gov
• Definition of telemedicine:
  • Medicaid: Telemedicine is “the use of telecommunication and information technology to provide clinical care to individuals at a distance, and to transmit the information needed to provide that care.” SOURCE: FL Dept. of Health, Child Protection Team Program, Program Handbook, p.65 (Jun. 28, 2019). (Accessed July 2021).
  • Private payers: “Telehealth” means the use of synchronous or asynchronous telecommunications technology by a telehealth provider to provide health care services, including, but not limited to, assessment, diagnosis, consultation, treatment, and monitoring of a patient; transfer of medical data; patient and professional health-related education; public health services; and health administration. The term does not include audio-only telephone calls, e-mail messages, or facsimile transmissions. SOURCE: FL Statute 456.47. (Accessed July 2021).

• Link to application: https://eservices.nysed.gov/professions/before/060
• License application guidance:
  • Requirements here. Applicant checklist here.
  • You can become licensed either (1) on the basis of endorsement, or (2) on the basis of acceptable examination scores if you have ever failed any part of USMLE, FLEX, or any other acceptable exam, without subsequently passing it.
  • All graduates of medical education programs that are neither registered by New York State nor accredited by the LCME or AOA, are required to use the Federation Credentials Verification Service (FCVS) to collect their education credentials.
• Associated costs:
  • Licensure fee: $735
• Contact information: New York State Education Department, Office of the Professions; OPOnlineApplications@nysed.gov, contact form here
• Definition of telemedicine:
  • Medicaid:
    • “Telehealth” means the use of electronic information and communication technologies by telehealth providers to deliver health care services, which shall include the assessment, diagnosis, consultation, treatment, education, care management and/or self-management of a patient. Telehealth shall not include delivery of health care services by means of facsimile machines, or electronic messaging alone, though use of these technologies is not precluded if used in conjunction with telemedicine, store and forward technology, or remote patient monitoring. For purposes of this section, telehealth shall be limited to telemedicine, store and forward technology, remote patient monitoring and audio-only telephone communication, except that with respect to the medical assistance program established under section three hundred sixty-six of the social services law, and the child health insurance plan under title one-A of article twenty-five of this chapter, telehealth shall include audio-only telephone communication only to the extent defined in regulations as may be promulgated by the commissioner. This subdivision shall not preclude the delivery of health care services by means of “home telehealth” as used in section thirty-six hundred fourteen of this chapter. SOURCE: NY Public Health Law Article 29 – G Section 2999-cc, (Accessed Jul. 2021).
    • Telemental Health Services means the use of two-way real-time interactive audio and video to provide and support clinical psychiatric care at a distance. Such services do not include a telephone conversation, electronic mail message, or facsimile transmission between a provider and a recipient or a consultation between two physicians or nurse practitioners, or other staff, although these activities may support Telemental Health Services. SOURCE: NY Code of Rules and Regs. Title 14, Sec. 596.4(r) & NY Office of Mental Health, Telepsychiatry Standards Guidance, 2020, pg. 2, (Accessed Jul. 2021).
  • Private Payers: Telehealth means the use of electronic information and communications technologies by a health care provider to deliver health services to an insured individual while such individual is located at a site that is different from the site where the health care provider is located. SOURCE: NY Insurance Law Article 32 Section 3217-h & Article 43 Section 4306-g. (Accessed Jul. 2021).

• Link to application: https://www.mbp.state.md.us/mbpiml/default.aspx
• License application guidance:
  • Maryland offers the FSMB’s Uniform Application (UA) for initial medical licensure. Using the UA for Initial Medical Licensure in Maryland, linked above, is optional, however, this online application works best in conjunction with the UA.
  • Instruction form here.
• Associated costs:
  • Application processing fee: $310 ($410 for International Medical School Graduates)
  • Prorated monthly licensure fee: $20 (assessed from the month of license application approval to the month of license expiration. Prorated licensure fee will not exceed $480)
  • UA fee: $60 (optional)
  • License verification fee: $17
  • Total cost: up to $867 ($967 for International Medical School Graduates)
• Contact information:
  • Maryland Board of Physicians, 410-764-4777 or 800-492-6836
  • To register and/or retrieve your FID number, go to https://www.fsmb.org/uniform-application or call the FSMB at 888-275-3287.
  • The UA FAQ at http://www.fsmb.org/uniform-application/ua-faq/ answers the most common UA questions. If your question or issue isn't listed, contact UA Customer Service at 800-793-7939 or email ua@fsmb.org. Provide your username and, if applicable, your FCVS ID number. If you receive an error, email a screenshot of the error along with a description of what you were doing at the time to ua@fsmb.org
  • For general licensure questions, email mbpmail@rcn.com
  • For non-UA technical support, contact Brenda Jones at 410.764.4736 or email brenda.jones@maryland.gov
• Definition of telemedicine:
  • Medicaid:
    • Telehealth means the delivery of medically necessary somatic, dental, or behavioral health services to a patient at an originating site by a distant site provider through the use of technology-assisted communication.
    • Telehealth includes:
      • Synchronous and asynchronous interactions;
      • From July 1, 2021, to June 30, 2023, both inclusive, an audio-only telephone conversation between a health care provider and a patient that results in the delivery of a billable, covered health care service; and
      • Remote patient monitoring services.
    • Telehealth does not include the provision of health care services solely through:
      • Except as provided above, an audio-only telephone conversation;
      • An e-mail message; or
      • A facsimile transmission.
    • SOURCE: MD Health General Code 15-141.2 (As amended by HB 123/SB 3 (2021 Session). Accessed Aug. 2021.
  • Private Payers:
    • Telehealth means, as it relates to the delivery of health care services, the use of interactive audio, video, or other telecommunications or electronic technology by a licensed health care provider to deliver a health care service within the scope of practice of the health care provider at a location other than the location of the patient.
    • Telehealth includes from July 1, 2021, to June 30, 2023, both inclusive, an audio-only telephone conversation between a health care provider and a patient that results in the delivery of a billable, covered health care service. Telehealth does not include:
      • except as provided in paragraph (2) of this subsection, an audio-only telephone conversation between a health care provider and a patient;
      • an electronic mail message between a health care provider and a patient; or
      • a facsimile transmission between a health care provider and a patient.
    • SOURCE: MD Insurance Code 15-139 (As amended by HB 123/SB 3 (2021 Session). (Accessed Aug. 2021).

• Links to application:
  • If you have an MD degree: http://www.dhp.virginia.gov/Boards/Medicine/ApplicantResources/ApplyforLicense/Medicine/
  • If you have a DO degree: http://www.dhp.virginia.gov/Boards/Medicine/ApplicantResources/ApplyforLicense/OsteopathicMedicine/
• License application guidance:
  • If you have been in active practice for 5 years following postgraduate training, you can apply for licensure by Endorsement, which requires significantly less supporting documentation and takes significantly less time than applying for licensure by Application. Instructions here.
  • If you have not yet been in active practice for 5 years following postgraduate training, you must apply for licensure by Application. Instructions here.
• Associated costs:
  • Application fee: $302
  • Virginia Board of Medicine license verification fee: $17
  • NPDB self-query fee: $3
  • [If applying for licensure by Application]: Any costs associated with transmitting medical school transcripts
  • [If applying for licensure by Application]: USMLE score transmission: $70; COMLEX score transmission: $80
  • Total cost: ~$322 for applying for licensure by Endorsement, $392 (MDs) or $402 (DOs) for applying for licensure by Application
• Contact information: Virginia Department of Health Professions, 804-367-4444 or CallCenter@dhp.va.gov
• Definition of telemedicine:
  • Medicaid: Telemedicine is a means of providing services through the use of two-way, real time interactive electronic communication between the member and the Provider located at a site distant from the member. This electronic communication must include, at a minimum, the use of audio and video equipment. Telemedicine does not include an audio-only telephone. SOURCE: VA Dept. of Medical Assistant Svcs., Medicaid Provider Manual Supplement-Telehealth Services (Available in multiple manuals, including physician/practitioner, see overview for full list), (July 2021) (Accessed Sept. 2021).
  • Private payers: “Telemedicine services” as it pertains to the delivery of health care services, means the use of electronic technology or media, including interactive audio or video, for the purpose of diagnosing or treating a patient, providing remote patient monitoring services, or consulting with other health care providers regarding a patient’s diagnosis or treatment, regardless of the originating site and whether the patient is accompanied by a health care provider at the time such services are provided. “Telemedicine services” does not include an audio-only telephone, electronic mail message, facsimile transmission, or online questionnaire. Nothing in this section shall preclude coverage for a service that is not a telemedicine service, including services delivered through real-time audio-only telephone. SOURCE: VA Code Annotated Sec. 38.2-3418.16 (Accessed Sept. 2021)

Permits providers to practice across state lines without a license if irregular or infrequent (defined as less than 10 times per year or involves fewer than 10 patients in a calendar year or comprises less than 1% of the provider’s practice). Ala Code 34-24-505(b); Ala Admin Code r. 540-X-16-0.2(2)(b), (4).

Permits providers to practice across state lines without a license if limited to an occasional case, does not establish or regularly use hospital connections in the state, or is provided with or has regular use of an office in the state. Ark. Code 17-95-203(2) [Doesn’t define occasional case]

Permits providers to treat existing patients, provided that the provider is delivering follow-up care to treatment that was originally provided in a state in which the provider was licensed. It also has an exception for treating existing patients if the patient is traveling. 225 ILCS 60/49.5(c)(3)-(4).

Permits out-of-state physicians to provide diagnostic or treatment services to Indiana patients following medical care originally provided to the patient while outside Indiana. Ind. Code § 25-22.5-1-1.1(a)(4).

Permits providers to practice across state lines without a license if irregular or infrequent (defined as less than once a month or fewer than 10 patients annually). Minn Stat 147.032-2(2)-(3)

Permits providers to practice across state lines without a license if limited to an occasional case (defined as not more than 2 cases per year. A single case may include rendering medical services to multiple patients on no more than 5 consecutive days). Mont Admin R 24.156.611(2)

Permits out-of-state physicians to treat their regular patients that are temporarily in North Carolina. N.C. Gen. Stat. § 90-18(c)(18).

Permits physicians to provide follow-up services to patients located in Ohio, provided that they were originally treated in the physicians’ state of licensure, for up to 1 year after the initial treatment and for the same condition. Ohio Rev. Code § 4731.36(A)(4).

Permits out-of-state physicians to treat existing patients that are temporarily in Oregon and that require direct medical treatment by that physician. Or. Rev. Stat. § 677.137(4); Or. Admin. R. 847-025-0020(3).

Permits out-of-state physicians to provide follow-up care to Washington patients provided that the treatment was performed in the physician’s state of licensure, the follow-up care is infrequent or episodic, and the physician does not set up an office in Washington. Washington Department of Health, Medical Quality Assurance Commission, Policy Statement regarding Telemedicine and Continuity of Care.

• Direct patient to a local provider if appropriate
• Convert upcoming OOS telemedicine visits with patients located outside of PA/NJ to one of the following:
  • In-person visit
  • Peer-to-peer consultations
  • Telephone call