Cross-State Telehealth Rules Explained: Where You Can Practice, Licensing Requirements, and DEA Considerations

Telehealth has opened incredible opportunities to expand your practice beyond state borders. But the legal landscape is complex—practice in the wrong state without proper licensing, and you risk serious consequences including fines, license suspension, and even criminal charges.

This comprehensive guide explains exactly where you can practice, what licenses you need, how interstate compacts work, and what DEA registration you need for prescribing across state lines.

The Golden Rule of Cross-State Telehealth

You must be licensed in the state where the patient is physically located during the telehealth visit.

It doesn't matter where you are. What matters is where your patient is.

Examples:

• ✅ You're in California, patient in California → Need California license only
• ✅ You're in California, patient in Texas → Need both California AND Texas licenses
• ✅ You're traveling in Florida, patient in New York → Need New York license (your location doesn't matter)
• ❌ You're in California, patient in Texas, you only have California license → ILLEGAL

The Exception: Some states participate in interstate compacts that allow you to practice across multiple states with one license. More on this below.

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State-by-State Licensing Requirements

States That Require Full Licensure

Most states require full, unrestricted licensure to practice telehealth:

No Shortcuts States (Full License Required):

• California
• New York
• Texas
• Florida
• Illinois
• Pennsylvania
• Ohio
• Georgia
• North Carolina
• Michigan
• New Jersey
• Virginia
• Washington
• Massachusetts
• Indiana
• Missouri
• Tennessee
• Maryland
• Wisconsin
• Minnesota
• Colorado
• Alabama
• South Carolina
• Louisiana
• Kentucky
• Oregon
• Oklahoma
• Connecticut
• Utah
• Iowa
• Nevada
• Arkansas
• Mississippi
• Kansas
• New Mexico
• Nebraska
• West Virginia
• Idaho
• Hawaii
• New Hampshire
• Maine
• Montana
• Rhode Island
• Delaware
• South Dakota
• North Dakota
• Alaska
• Vermont
• Wyoming

What This Means: To practice telehealth with patients in these states, you need a full, unrestricted license in that state—same as if you were practicing in person.

Interstate Compacts: The Game Changer

Interstate compacts allow you to practice in multiple states with streamlined licensing.

Available Compacts:

1. Nurse Licensure Compact (NLC) - For RNs and LPNs

• 39 participating states (as of 2026)
• Allows RNs and LPNs to practice in all compact states with one license
• Does NOT include PMHNPs (they need APRN Compact)

2. APRN Compact - For Nurse Practitioners (Including PMHNPs)

• Launched 2023, growing adoption
• Participating states (2026): Delaware, Idaho, Kentucky, Maine, Maryland, Missouri, Montana, Nebraska, New Hampshire, North Carolina, North Dakota, Oklahoma, South Dakota, Tennessee, Utah, West Virginia, Wyoming
• Allows PMHNPs to practice in all compact states with one multistate license
• Major states NOT in compact: California, New York, Texas, Florida, Illinois, Pennsylvania

How APRN Compact Works:

1. Obtain license in your home state (must be compact state)
2. Apply for multistate privilege
3. Practice in all compact states without additional licenses
4. Must maintain home state license

3. Interstate Medical Licensure Compact (IMLC) - For Physicians

• 40 participating states (as of 2026)
• Streamlines process to get licenses in multiple states
• Not a single license—still need separate license for each state
• Faster, easier application process

How IMLC Works:

1. Hold license in IMLC state
2. Apply through IMLC portal
3. Designate which states you want licenses in
4. Pay fees for each state
5. Receive separate licenses for each state (faster process)

4. Psychology Interjurisdictional Compact (PSYPACT) - For Psychologists

• 40+ participating states (as of 2026)
• Allows psychologists to practice telepsychology across state lines
• Must hold license in home state (compact state)
• Can practice in all compact states

Major states NOT in PSYPACT: California, New York (as of 2026)

Special Telehealth Licenses

Some states offer special telehealth-only licenses:

States with Telehealth-Specific Licenses:

• Alabama: Telehealth license available
• Tennessee: Telemedicine license for out-of-state providers
• Texas: Considering telehealth-specific pathways
• Ohio: Telehealth certificate available

Limitations:

• Usually cheaper than full license
• Only for telehealth (can't practice in-person)
• May have restrictions on prescribing
• Not available in most states

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How to Get Licensed in Multiple States

Step-by-Step Process

Step 1: Determine Which States You Need

Questions to Ask:

• Where are my current patients located?
• Where do I want to expand?
• Which states have the most demand for my specialty?
• Which states participate in compacts?

Strategic Approach:

• Start with compact states if eligible
• Add high-demand states (California, New York, Texas, Florida)
• Consider states with large populations
• Look at states with provider shortages in your specialty

Step 2: Check Eligibility Requirements

Common Requirements:

• Active, unrestricted license in another state
• No disciplinary actions
• Passing scores on national exams (NCLEX, USMLE, EPPP, etc.)
• Continuing education credits
• Background check
• Fingerprints

Step 3: Gather Required Documents

Typical Documents Needed:

• Current license verification
• Medical/nursing school transcripts
• Exam scores (NCLEX, USMLE, EPPP, etc.)
• Continuing education certificates
• Malpractice insurance proof
• DEA certificate (if prescribing)
• Board certification (if applicable)
• Letters of recommendation (some states)
• Work history
• Explanation of any gaps in practice

Step 4: Apply Through State Board

Application Process:

• Complete online application
• Upload documents
• Pay application fee ($100-500 per state)
• Submit fingerprints for background check
• Wait for processing (2-6 months typically)

Step 5: Maintain Licenses

Ongoing Requirements:

• Renewal fees (every 1-2 years)
• Continuing education (varies by state)
• Keep all licenses active
• Report any changes (address, name, disciplinary actions)

Cost of Multi-State Licensing

Initial Costs Per State:

• Application fee: $100-500
• Background check: $50-100
• Fingerprints: $50-100
• License fee: $100-400
• Total per state: $300-1,100

Annual Renewal Costs:

• Renewal fee: $100-400 per state
• Continuing education: $200-500 per year (covers multiple states)
• Total annual: $100-400 per state

Example: PMHNP with 5 State Licenses

• Initial setup: $1,500-5,500
• Annual renewal: $500-2,000
• Continuing education: $200-500
• Total first year: $2,200-8,000
• Annual ongoing: $700-2,500

ROI Calculation:

• Cost per state: $300-500/year
• Revenue per state: 5-10 new clients × $150/session × 10 sessions = $7,500-15,000
• ROI: 1,500-3,000% (excellent return)

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DEA Registration for Prescribing Across State Lines

DEA Basics

What is DEA Registration?

• Required to prescribe controlled substances
• Issued by Drug Enforcement Administration
• Separate from medical/nursing license
• Required for each state where you prescribe

Who Needs DEA Registration:

• Physicians
• Nurse Practitioners (including PMHNPs)
• Physician Assistants
• Dentists
• Veterinarians

Who Doesn't Need DEA:

• Therapists (LPC, LMFT, LCSW)
• Psychologists (unless prescribing authority in specific states)
• RNs without prescribing authority

DEA Registration for Telehealth

The Rule: You need a DEA registration in every state where you prescribe controlled substances to patients.

Examples:

• You're in California, prescribing to California patients → Need California DEA
• You're in California, prescribing to Texas patients → Need both California AND Texas DEA
• You prescribe in 5 states → Need 5 DEA registrations

Cost:

• Initial DEA registration: $731 (3 years)
• Renewal: $731 (every 3 years)
• Per state per year: ~$244

Special Telehealth DEA (COVID-Era Rules): During COVID, special rules allowed prescribing across state lines with one DEA. These expired in 2023. You now need separate DEA for each state.

EPCS (Electronic Prescribing of Controlled Substances)

What is EPCS?

• Electronic prescribing of Schedule II-V controlled substances
• Requires special DEA certification
• Two-factor authentication required
• More secure than paper prescriptions

EPCS Requirements:

• DEA registration with EPCS approval
• EPCS-certified software (ClinikEHR is EPCS-certified)
• Two-factor authentication (usually phone + password)
• Identity proofing process

How to Get EPCS:

1. Have active DEA registration
2. Complete identity proofing (in-person or video)
3. Set up two-factor authentication
4. Use EPCS-certified EHR
5. Prescribe electronically

Benefits:

• Faster for patients (no pharmacy trips for paper scripts)
• More secure (can't be altered or forged)
• Required by many states for controlled substances
• Reduces prescribing errors

States Requiring EPCS:

• New York (required)
• Minnesota (required for controlled substances)
• Many others strongly encourage or will require soon

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Prescribing While Traveling

The Scenario

You're a PMHNP licensed in California with California DEA. You're traveling in Florida. Can you prescribe to your California patients while in Florida?

The Answer: Yes, with conditions

What You Need:

• ✅ Active California license (where patient is located)
• ✅ Active California DEA (where patient is located)
• ✅ EPCS capability (recommended)
• ✅ Secure internet connection
• ✅ HIPAA-compliant telehealth platform

What You DON'T Need:

• ❌ Florida license (you're not treating Florida patients)
• ❌ Florida DEA (you're not prescribing to Florida patients)

Important Considerations:

1. Document Patient Location Always document where the patient is physically located during the visit. This is required for compliance.

2. Use Secure Connection

• Don't use public WiFi without VPN
• Use HIPAA-compliant telehealth platform
• Ensure privacy (not in public spaces)

3. State-Specific Rules Some states have rules about prescribing while traveling. Check your state's medical/nursing board.

4. Malpractice Insurance Verify your malpractice insurance covers telehealth and out-of-state practice.

Common Travel Scenarios

Scenario 1: Vacation

• You're on vacation in Hawaii
• Your California patients need refills
• Solution: You can prescribe to California patients from Hawaii (need California license + DEA)

Scenario 2: Temporary Relocation

• You're spending 3 months in Arizona
• You want to see your California patients
• Solution: You can continue treating California patients (need California license + DEA)

Scenario 3: Snowbird

• You split time between New York (summer) and Florida (winter)
• You want to treat patients in both states
• Solution: Need licenses and DEA in both New York AND Florida

Scenario 4: Digital Nomad

• You travel full-time
• You want to treat patients in multiple states
• Solution: Get licenses in all states where you treat patients (consider compact states)

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State-Specific Telehealth Rules

States with Unique Requirements

California:

• Requires California license for any patient in California
• No telehealth-specific license
• Must establish provider-patient relationship (can be via telehealth)
• Prescribing rules same as in-person

New York:

• Requires New York license for any patient in New York
• Strict prescribing rules
• EPCS required for controlled substances
• Must use HIPAA-compliant platform

Texas:

• Requires Texas license for any patient in Texas
• Must establish provider-patient relationship before prescribing
• Can establish relationship via telehealth
• Strict rules on prescribing controlled substances

Florida:

• Requires Florida license for any patient in Florida
• Must register with Florida Board if practicing telehealth
• Prescribing rules same as in-person
• Must use HIPAA-compliant platform

Massachusetts:

• Requires Massachusetts license for any patient in Massachusetts
• Must establish provider-patient relationship
• Can establish via telehealth
• Prescribing allowed via telehealth

States with Telehealth Parity Laws

Telehealth parity means insurance must reimburse telehealth same as in-person.

States with Strong Parity Laws:

• California
• New York
• Texas
• Florida
• Illinois
• Pennsylvania
• Ohio
• Most other states (48 states have some form of parity)

What This Means:

• Insurance pays same rate for telehealth as in-person
• Can't require in-person visit first (in most cases)
• Must cover same services via telehealth

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Compliance and Risk Management

Documentation Requirements

What to Document for Every Telehealth Visit:

Patient Location:

"Patient confirmed they are physically located in [City, State] for today's telehealth visit."

Your Location (if relevant):

"Provider is physically located in [City, State] during this telehealth visit."

Technology Used:

"Telehealth visit conducted via [platform name], HIPAA-compliant video platform."

Consent:

"Patient provided informed consent for telehealth services, including understanding of 
technology limitations and privacy considerations."

Clinical Note: Document same as in-person visit, plus telehealth-specific elements above.

Common Compliance Mistakes

Mistake 1: Practicing Without Proper License Problem: Treating patients in states where you're not licensed Consequence: License suspension, fines, criminal charges Solution: Get licensed in all states where you treat patients

Mistake 2: Prescribing Without DEA Problem: Prescribing controlled substances without DEA in patient's state Consequence: DEA violations, fines, loss of prescribing privileges Solution: Get DEA registration in all states where you prescribe

Mistake 3: Not Documenting Patient Location Problem: No record of where patient was located Consequence: Compliance violations, insurance denials Solution: Document patient location in every note

Mistake 4: Using Non-HIPAA Compliant Platforms Problem: Using Zoom, FaceTime, Skype for telehealth Consequence: HIPAA violations, fines, patient privacy breaches Solution: Use HIPAA-compliant platforms (ClinikEHR includes compliant telehealth)

Mistake 5: Not Verifying Insurance Coverage Problem: Assuming insurance covers telehealth in all states Consequence: Claim denials, patient billing issues Solution: Verify coverage before providing services

Malpractice Insurance Considerations

What to Verify:

• Does your policy cover telehealth?
• Does it cover practice in multiple states?
• Are there any state exclusions?
• What are the coverage limits?
• Do you need additional riders?

Typical Coverage:

• Most policies now include telehealth
• May need to notify insurer of additional states
• May need separate policy for some states
• Costs typically $1,000-5,000/year

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Strategic Planning for Multi-State Practice

Which States to Target First

Tier 1: High-Priority States

• California — Largest population, high demand
• Texas — Large population, provider shortage
• Florida — Large population, growing telehealth
• New York — High demand, good reimbursement

Tier 2: Compact States (If Eligible)

• APRN Compact states — 17 states with one license
• PSYPACT states — 40+ states for psychologists
• Strategic for rapid expansion

Tier 3: Specialty-Specific

• States with shortages in your specialty
• States with good reimbursement rates
• States where you have existing connections

Tier 4: Adjacent States

• States bordering your home state
• Easier to serve (similar time zones)
• May have existing patient demand

Building a Multi-State Practice

Year 1: Foundation

• Get licensed in home state
• Add 1-2 high-priority states
• Build systems and processes
• Test telehealth workflows

Year 2: Expansion

• Add 2-3 more states
• Join compact if eligible
• Optimize marketing for multi-state
• Hire support staff if needed

Year 3: Optimization

• Add remaining target states
• Streamline operations
• Focus on high-ROI states
• Consider dropping low-volume states

Year 4+: Maintenance

• Maintain licenses in profitable states
• Drop unprofitable states
• Focus on quality over quantity
• Optimize for work-life balance

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Technology Requirements

HIPAA-Compliant Telehealth Platforms

Required Features:

• End-to-end encryption
• Business Associate Agreement (BAA)
• Secure video and audio
• Recording capability (with consent)
• Screen sharing
• Mobile access
• Reliable connection

Recommended Platforms:

• ClinikEHR — Integrated telehealth + EHR
• Doxy.me — Simple, HIPAA-compliant
• Zoom for Healthcare — Enterprise solution
• VSee — Healthcare-specific

What NOT to Use:

• ❌ Regular Zoom (without healthcare plan)
• ❌ FaceTime
• ❌ Skype
• ❌ Google Meet (without BAA)
• ❌ WhatsApp video

EHR Requirements for Multi-State Practice

Must-Have Features:

• Document patient location automatically
• Track licenses and DEA by state
• Support multi-state billing
• EPCS capability
• Telehealth integration
• Compliance reporting

ClinikEHR Features:

• Automatic patient location documentation
• Multi-state license tracking
• Integrated HIPAA-compliant telehealth
• EPCS certified
• Compliance alerts
• Multi-state billing support

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Related Resources

ClinikEHR Features

• HIPAA-Compliant Telehealth
• EPCS E-Prescribing
• Multi-State Practice Management
• Compliance Documentation

Related Guides

• How to Start a PMHNP Private Practice
• Top 5 EHR for Mental Health 2026
• EHR for Psychiatrist
• How to Market Your Telepsychiatry Practice

Official Resources

• Federation of State Medical Boards: https://www.fsmb.org/
• National Council of State Boards of Nursing: https://www.ncsbn.org/
• DEA Diversion Control: https://www.deadiversion.usdoj.gov/
• IMLC: https://www.imlcc.org/
• APRN Compact: https://www.aprncompact.com/
• PSYPACT: https://psypact.org/

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Frequently Asked Questions

Can I practice telehealth across state lines without additional licenses? Only if you're part of an interstate compact (APRN Compact, PSYPACT, etc.) and practicing in compact states. Otherwise, you need a license in every state where your patients are located.

Do I need a DEA registration in every state where I prescribe? Yes—you need a separate DEA registration in every state where you prescribe controlled substances to patients, even via telehealth. Cost is $731 per state for 3 years.

Can I prescribe to my patients while traveling? Yes—you can prescribe to patients in states where you're licensed, regardless of where you're physically located. You need a license and DEA in the state where the PATIENT is located, not where you are.

What happens if I practice without proper licensing? Serious consequences including license suspension or revocation, fines up to $10,000+, criminal charges in some cases, and malpractice liability. Never practice without proper licensing.

How long does it take to get licensed in a new state? Typically 2-6 months depending on the state. Some states are faster (1-2 months), others slower (6-12 months). Plan ahead and apply early.

Is the APRN Compact worth it for PMHNPs? Yes, if you want to practice in multiple compact states. One license covers 17 states (as of 2026). However, major states like California, New York, Texas, and Florida are NOT in the compact, so you'll still need separate licenses for those.

Can I use regular Zoom for telehealth? No—regular Zoom is not HIPAA-compliant. You need Zoom for Healthcare (with BAA) or another HIPAA-compliant platform. Using non-compliant platforms risks HIPAA violations and fines.

Do I need malpractice insurance for telehealth? Yes—verify your current policy covers telehealth and multi-state practice. You may need additional coverage or riders for some states. Typical cost: $1,000-5,000/year.

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Conclusion: Expand Safely and Legally

Cross-state telehealth offers incredible opportunities to grow your practice and serve more patients. But it requires careful attention to licensing, DEA registration, and compliance.

Key Takeaways:

• ✅ You must be licensed where the PATIENT is located
• ✅ Interstate compacts can simplify multi-state practice
• ✅ You need separate DEA for each state where you prescribe
• ✅ Document patient location in every note
• ✅ Use HIPAA-compliant telehealth platforms only
• ✅ Verify malpractice insurance covers multi-state practice
• ✅ Plan strategically—start with high-priority states

Action Steps:

1. Determine which states you want to practice in
2. Check if you're eligible for interstate compacts
3. Apply for licenses in target states (allow 2-6 months)
4. Get DEA registration in states where you'll prescribe
5. Set up HIPAA-compliant telehealth platform
6. Verify malpractice insurance coverage
7. Document patient location in every visit

The investment in multi-state licensing pays off quickly—5-10 new clients per state generates $7,500-15,000 in revenue, far exceeding the $300-500 annual cost per license.

Start Your Free 30-Day Trial — ClinikEHR tracks licenses, documents patient locations, and keeps you compliant.

Questions about multi-state telehealth? Contact our team — We help practitioners navigate cross-state practice every day.

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Disclaimer: This article provides general information for educational purposes. Telehealth laws and regulations change frequently and vary by state and profession. Always consult your state licensing board, legal counsel, and professional liability insurance provider before practicing across state lines. This is not legal advice.