One of the more debated areas of telehealth policy is the "established relationship" requirement — the idea that a physician generally needs some prior contact with a patient, often an initial evaluation of a particular kind, before prescribing certain medications through a virtual visit. Not every state has this requirement, and where it exists, the details differ considerably.
What the requirement generally covers
In states that maintain some version of this rule, it typically applies most strictly to controlled substances rather than to routine prescribing. The underlying concern is that prescribing certain medications, particularly those with abuse potential, without ever having examined or spoken with a patient in a more thorough encounter raises safety and diversion concerns that regulators have historically tried to address through in-person or synchronous evaluation requirements.
How the rule has evolved
Historically, federal policy under the Ryan Haight Act generally required an in-person evaluation before prescribing controlled substances via telemedicine, with certain exceptions. Temporary flexibilities introduced during the COVID-19 public health emergency relaxed this for a period, and policymakers have continued to debate permanent rules since. State requirements have moved somewhat independently of federal policy, so a state's established-relationship rule may be stricter, looser, or roughly aligned with current federal flexibilities at any given time.
An established relationship requirement is less a single national rule than a patchwork of state-by-state judgment calls layered on top of shifting federal policy.
What counts as "established"
States that have this requirement typically accept a synchronous audio-video evaluation as sufficient to establish the relationship, though some historically required an in-person visit for certain prescriptions. A few states allow the relationship to be established through a covering physician or through documented prior treatment, provided proper records are available.
Why this matters for multi-state practice
A physician licensed in several states may find that a new-patient telehealth visit is entirely appropriate for prescribing in one state but requires an additional step, or is not permitted at all for certain drug classes, in another. This is one of the areas where treating all states as functionally identical can create real compliance risk.
Established relationship rules are set at the state level and interact with evolving federal policy, so requirements vary by state and change over time — always confirm current requirements directly with the relevant state board or agency before making a compliance decision.