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For more than a decade now, clinicians have asked us if they can practice telehealth across state lines, provincial lines, and international lines.
That answer is changing with COVID-19.
As always, formal permission for inter-jurisdictional practice depends on where you hold a license and how much your profession has done to get an inter-jurisdictional practice model put into effect across states. Practicing telehealth across state lines, provincial lines and/or international borders is possible.
Traditionally the process involved getting records from your academic institutions, supervisors, licensing board and in some cases, paying fees. Then, waiting for weeks or months for it all to come together before submitting it all to a foreign licensing board for review. That final review process would often require yet more weeks or months, and more fees before approval to practice telehealth across state lines.
In the time of COVID-19, we see dramatic changes in the number of states expediting their previous processes for inter-jurisdictional practice.
Physicians & the Interstate Medical Licensure Compact for Telehealth Across State Lines
For physicians, the Federation of State Medical Boards (FSMB) has been visibly active in developing a Model Act. The act helps physicians gain access to cross-state and provincial licensure and registration through their Interstate Medical Licensure Compact (IMLC). The Compact offers a voluntary expedited pathway to licensure for qualified physicians who want to practice in multiple states.
The FSMB received a grant from the Office for the Advancement of Telehealth (OAT). Then the FSMB crafted a model act that leads to the expedited transfer of documents between states after physicians meet IMLC conditions.
Designed to increase access to health care for patients in underserved or rural areas, the IMLC’s goal was to allow physicians to more easily connect with medical experts through the use of telehealth across state lines.
The IMLC application process is expedited during COVID-19 by leveraging the physician’s existing information previously submitted in their state of principal license (SPL). The SPL verifies the physician’s information, then conducts a fresh background check. Once qualified, the Physician may practice in any number of other Compact states.
Psychology Interjurisdictional Compact (PSYPACT)
Psychologists have also made headway toward inter-jurisdictional practice. Known as the Psychology Interjurisdictional Compact (PSYPACT), the psychologist’s Model Act involves an interstate compact designed to facilitate the practice of telepsychology and the temporary in-person, face-to-face practice of psychology and telehealth across state lines.
A commission was formed and met in the summer of 2019 to define the Bylaws and Rules and Regulations under which psychologists would be allowed to apply and work in states who formally accept the PsyPACT Model Act as state law. According to the PSYPACT website, to date, 15 states have done approved the PSYPACT, but the PSYPACT Commission has not yet finalized the Rules needed.
ASPPB has acted swiftly to gather information from its member licensing boards and made the results of their work available through their website. The reader is directed to the ASPPB page that describes current COVID-19 activities and the ASPPB commitment to provide COVID-19 updates regularly as they develop.
That page also provides links to these COVID-19 related documents, which may be of use to the reader:
- Temporary Interjurisdictional Telepsychological Practice & COVID-19 -This document is a state-by-state reporting of COVID-19 changes of relevance to inter-jurisdictional practice for psychologists.
- CE Requirement Adjustments
- Supervision Hours for Licensure via Tele-means
- Pearson COVID-19 Update
Other Movement by Behavioral Professions for Telehealth Across State Lines?
TBHI is not aware of activity along these lines by any other associations, even during the COVID-19 crisis. So, if you can help shed light on these issues with regard to your profession, please comment below. We will update this page as more information is available.
For more COVID-19 telehealth information that is specific to telebehavioral health, the Telebehavioral Health Institute offers you a listing of other legislative changes HERE: Telehealth Primer for COVID-19.
Marlene M. Maheu, PhD has been a technologist-psychologist and pioneer since 1994. She has served various organizations to assist with the development of technology-focused standards and guidelines, including the American Telemedicine Association, the American Psychological Association and the American Counseling Association. She has overseen the development and delivery of telehealth training to more than 41,000 professionals worldwide and consulted with hundreds of hospitals, clinics, agencies, groups and independent practitioners seeking start-up guidance.
Telehealth: How to Legally and Ethically Practice Over State Lines & International Borders
Practicing telehealth across state lines or international borders? Operate legally & ethically 100% of the time.
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What are your thoughts about this article? Please comment below.
Hello. I will be completing my PMHNP in August. I am licensed in Maryland and my home state, Pennsylvania. Can a PMHNP do telemedicine when they are temporarily residing outside of the country? We have a second home in the Dominican Republic.
Jennifer, In most cases, yes, professionals licensed to serve citizens in one state, those people can be served from anywhere in the world. HOWEVER, this is not true in 100% of the states. Check with your licensing board directly. Do not trust anyone else to tell you your board’s regulations because the boards are changing rapidly. Also, ask your board how you can stay informed if they change their regulations at any point in the future. Always do what your board tells you to do. They hold your meal ticket – your ability to work.
Hello! I am an LMFT in North Carolina and am currently residing in Germany as my spouse is with the US military. I have checked with the NC Board who confirmed that I would be able to continue providing telehealth services to NC clients. My understanding of telehealth is that I also may be subject to the laws and rules of Germany. I do not intend to practice nor see clients here in Germany whatsoever, just clients residing in NC. I have contacted the Baden-wurttemberg authorities in this matter as well. Any insight or information in this regard would be greatly appreciated! Thank you so very kindly!
Hello! I am an LPC in Oregon and am looking at moving to California temporarily and am wondering if I will be able to continue to see my clients in Oregon via Telehealth?
Zoe, Thank you for your inquiry. No matter what anyone tells you, the only 100% accurate source of information is your licensing board and the board of the state you are visiting. States can differ widely and they are in rapid flux, too. Contact your Oregon licensing board to ask them how to proceed, and then contact the CA Board of Behavioral Sciences (BBC). Do what they say 100%. If their opinions conflict, you may want to follow the direction of the more stringent of the two. Crazy but true…
If you don’t agree with their policy, respectfully register your opinion with them in writing. Cite how their policy can damage the client involved, and without revealing identifying details, summarize the case and why the policy is unduly restrictive. Boards will only change if they get enough of these types of letters. Be an advocate for your profession and take a stand. The thing I like about the ACA ethics code is that it requires that all counselors be advocates for the profession. I have not seen the AAMFT or any other code require advocacy, but I admire the ACA for making advocacy an ethical mandate…
I also encourage you to contact these boards by email because email will give you a date and time stamp that you can use later if needed. Document your contact date and time as well as the response of both boards in your notes for each client involved, along with your course of action.
I’m wondering if it’s possible to maintain licensure as a LMHC working with clients in private practice (out of network) in NYC while living abroad? Basically to continue work with clients who are NYC-based, with an NYC license, but completely remote abroad.
Lynn, Thank you for your inquiry. Most states will approve your delivery of healthcare services to citizens of a state where you are licensed when anywhere outside the state, including when you are abroad. However, rules and requirements are changing quickly because of COVID. It is always safest to send an email to your licensing board to see if they object. Most email suggestions will get a response within a week, depending on your board.
An American citizen living in China temporarily needs psychological therapy from the u.s urgently. What should we do?
Judy, Speak to your licensing board. Do not ask anyone who isn’t on your board. There are many wannabee “telehealth experts” out there who will give you their opinion. Only your board knows what your board wants you to do.
I am an LCSW in the state of North Carolina, am I allowed to treat clients outside of North Carolina. All of these clients are cash payments, none are going through insurance.
Hi,
I am a licensed marriage and family therapist in California. I have a client who will be working for 8 months in Costa Rica and another who will be in London for 6 months. Do you know how I can find out if I’m able to continue meeting with them while they are temporarily in these locations? If so, I could sure use some guidance. Thank you!
Hi Dr.Maheau,
My 21 yr old child goes to school in a different state but will be coming home to CAlifornia for few weeks. We really want him to continue his psychiatrist and therapist sessions with his current providers while he is here. Is that possible to do?
The psychiatrist needs to contact the medical board in your state to see what s/he must do to treat your child liegally. Under COVID, most states are simply having the professional fill out a simple form that is available on the foreign state’s (your state) website. Should take 5 minutes.
Hi there,
Hope all is well with you! Thank you for this info.
I am trained and registered (licensed) as Psychologist in the UK. Can I deliver teletherapy un the US?
Larissa
Larissa,
If you work in any of the US states without being properly documented, you are practicing illegally. To practice in the US legally, you need to be licensed, registered or otherwise documented with an affidavit from the state where your client is located at the time of your work with them. Because this jurisdictional licensing issue is a serious impediment to the growth of telehealth, many of us in the telehealth community have been fighting to get things changed for decades. Now with COVID, if the US citizens reading this message write to their legislators at this critical moment in time, we may actually see meaningful change.
Hi there, i am trying to understand if u do telehealth across state line do u have to register yourself/llc in every state or that rule doesn’t apply to online work. Appreciate any feedback in that area.
S kumar,
Thank you for aksing your question. many professionals have the same question. Practicing online counts the same as in person, so yes, you have to register, complete an affidavit or get licensed in all states where you deliver care. The same is true for Candian provinces.
All legal and ethical requirements apply, whether or not your state or province explains or even mentions the difference between in-person and online. The assumption, for example, is that you have to protect a patient’s privacy. Where and how you do that is up to you to learn and practice, however and wherever you deliver care. Furthermore, if the clinician doesn’t understand exactly how the in-person rules apply online, the job of that clinician is to get trained – which is is why our organization exists.
Many clinicians didn’t learn how to practice online, so come to us to take the needed courses, and many also want to get certified. See our courses here: https://blog.telehealth.org/trainingcatalog/ and three levels of certificates here: https://blog.telehealth.org/telehealth-certificates/ States want us to deliver professional-level care, and often evidence-based professional-level care everywhere that we practice. We at telehealth.org deliver just that, evidence-based telehealth training and consultation. For practicing over state lines, this recently recorded course will answer most of your questions: https://blog.telehealth.org/telehealth-across-state-lines/
I am a binational (Mexico/U.S), and reside in Mexico; I´m licensed by the Mexican Board of Professional Regulation to practice psychology. Would U.S. regulating boards allow me offer telepsychology to Mexican nationals who are currently living in the U.S. ?
Also; a few of my patients are Americans who reside part-time within Mexico. When they return to the U.S. (sometimes just for a short stay) must I cease offering them any mode of online therapy? I am not licensed as a U.S. psychologist.
I am also conducting psychotherapy with an Australian, here in Mexico. Can we continue his therapy, via Web-cam — once this client returns to Australia?
I am appreciative of your feedback.
Ramona, Thank you for your question. Many professionals share the same interests, so I’m going to paste the response I just recently gave to Larissa, who had the same question last week: Our understanding after researching ad teaching professionals for 28 years is that if you work in any of the US states without being properly documented, you are practicing illegally. To practice in the US legally, you need to be licensed, registered or otherwise documented with an affidavit from the state where your client is located at the time of your contact with them.
To answer you even more specifically, it doesn’t matter who the people are that you serve. They can be from Switzerland, Tibet or Mexico – if they are on American soil, telehealth law follows the patient and the jurisdiction they are in. If the patient is in Texas, then Texas law rules – not the state or country of their residence.
Licensure is much like the driving law in this one respect. If a Mexican from Puerto Vallarta has an auto accident in Texas, the law of Texas would be the law that rules, not the law in Puerto Vallarta. If you have to go to court, you will go to court in Texas. Now I cannot speak to the issue with regard to you serving an Australian with your Mexican license.
In both cases, I strongly suggest that you write to your licensing board as well as that for your profession in the geographic region involved. Ask them for a response in writing before delivering care. (And please don’t shoot the messager. I literally have been working for 28 years to try and change things by educating our colleagues of this outdated situation and encouraging them to write to their licensing boards to lobby for change.
During Covid, can interns in Colorado supervised by a Colorado Licensed Professional Counselor in Colorado counsel clients in California?
Different boards have different rules in different states, and even within states. Psychologist boards might require something quite different from medical boards or counseling boards. You might want to write to both boards involved for your profession by email, and ask them to respond. We suggest that you always get such information in writing directly from the boards. No one else’s opinion matters.
This is an interesting post. I have a question. I am an American psychologist from California, but I live in France and work as a registered psychology in France. I have a new french patient who is interested in session, but she is living in Boston. Can I treat her? Or does she have to see someone with a Massachusetts license?
Valene, Licesning rules follow the patient. If she is in Boston, you have to get squared away with the Mass psychology board. During COVID, you are likely to be able to write to the Mass board (by email) and ask them if they offer an “affidavit.” Or you can look on their website. If they offer one, it will take 3 minutes to complete and you will be legitimate.
I am a licensed MFT in California and will be spending an extended vacation period of time in Mexico. I would like to continue seeing my clients here in CA via telehealth while I am there. My licensing board here states that I can do this as long as I meet requirements for providing psychotherapy services in Mexico and Mexico allows telehealth. I have been searching the internet for information on Mexico laws related to telehealth and to psychotherapy but have not found the information. Can you guide me to the correct authorities in Mexico to answer these two questions?
However ridiculous it may seem, the boards rule. The one suggestion that I can offer is for you to contact the Mexican embassy and ask them who in Mexico can potentially give you the needed authorization.
Hello,
I am also a licensed MFT in CA and would like to be able to provide therapy for clients in CA while in Mexico. Were you able to navigate the process of making this happen? Will it only work for cash pay? Thanks for any help!
Erin
Hello Erin, Thank you for your question. I see that you didn’t get an answer from the person who responded to our blog post, so please allow me to inviter you to our up-to-date, 1-hour webinar on the “how-to’s,” click here: Telehealth: How to Legally and Ethically Practice Over State Lines & International Borders
I am a licensed psychologist in the State of New York. What is needed for NYS to participate in PSYPACT?
Maureen, You may want to visit the ASPPB.org website for specific information. The PSYPACT.com site is also available, but to date, it seems to have fewer answers than the parent site, ASPPB.
Hello. I have been a licensed psychologist for over 30 years and currently am licensed in CO and NY. We just moved to MD, and I decided to retire since it was not practical to set up another private practice during covid. However, I have been asked by a licensed Master’s level therapist to supervise her. She does not require a signature for supervision hours, just would like to have someone for case consultation on difficult therapeutic issues. Would I need a MD license to provide such supervision, or could she just pay me for “consulting services”.
Beanne, You may want to go to “Google Scholar” or PuBMED and look for articles and books that discuss, define and outline differences between consultation and supervision. Then look for telehealth-related articles on these differences. Stick to the research that you find. Technically, consultation is allowed over state lines but is NOT the same as supervision. Consultation also isn’t the same as treatment. I’d suggest that you be very conservative in how you wotk with this person, if you choose to do so – and keep very detailed notes. Refer to the research articles or books that you find on the matter. You may also want to consult with your malpractice company’s attorney and follow their recommendations.
Marlene,
I am licensed in Maryland for professional counselling. A former client will be returning to Maryland after living abroad in Jordon for a year. She wishes to begin counseling sessions again which due to the pandemic I am providing via a tele-mental health platform. Flight delays have delayed her return to a day or two after our first scheduled session in this renewal of services. Out of an abundance of care, I have searched the web to see if I can find regulatory information regarding the delivery of counseling services to folks in Jordon and I cannot find any relevant information. Before I tell my returning client she must wait until she touches down in Maryland to begin remote counseling services with me again, I wondered if you can direct me to a resource that might inform me of the legality of briefly providing those remote counseling services while she is still in Jordon.
Susan, Contact your licensing board in writing. Most board reply to email within a few days. Don’t listen to anyone else but your board. Everyone else is guessing. Only your board knows what they want, and it can be quite different from other boards.
I am a physician licensed in Virginia. I will in Florida during the winter (2 months). I wish to continue seeing Virginia patients during this time. I have not been able to get a straight answer from either Boards and have conflicting answers from colleagues. Does anyone know what I need to do? Thanks.
I am a Licensed Professional Clinical Counselor in California. A client, an American citizen is temporarily moving to BC, Canada. The BC counselor’s association basically told me to check w my state agency. Any more thoughts on American therapists doing teletherapy with folks situated in Canada?
Thanks,
Shelley
Shelley,
You went to the association, which probably has nothing to do with licensing. People answering the phone are also not reliable sources because they may or may not know telehealth answers. In Canada, licensing boards are called Colleges. You may want to contact the Collge for your profession in BC and ask them what is needed to work in their province. Send them an email so that you have a written statement. People tend to give information when they have to write it down, and you will then have a document to put into your patient or client file if questioned.
Hello Shelley,
We are in a similar situation. Were you able to find anything out that enables you to continue working with your client who is relocating to BC from California?
Thank you so much, Verna
Verna, You may want to see the responses that other people have obtained above for this type of issue. Bottom line, contact all licensing boards involved, and do it in writing, preferably email. Only they can give you definitive answers, but more than likely, you are fine to practice in most states if you complete an affidavit in the foreign state.
Hello Dr. Maheu, I am a psychiatric nurse practitioner providing Telehealth to all my patients during the pandemic. Since the pandemic started I have had a few patients that have moved out of Maryland, the State where I have my license. I know there are certain exception guidelines during this pandemic, but another question I had was if I have already established a relationship with these patients in my State can I continue to treat them in their new State?
Thank you,
Lisa
Lisa, I answered Felicia a few moments ago, so I will paste my response here in case you miss it:
To practice legally over state lines, licensed professionals in the United States have to inform all involved boards in writing for your particular profession at all times. To my knowledge, there are no exceptions to those rules, but if anyone here knows of one, please comment. It is easy enough to go to the board’s website in a foreign state and either contact them by email or look around to see if you can find their position statement about licensed professionals working in their state with a foreign license.
During COVID, you do that by going to the board for your profession in whatever state and look for an “affidavit” to sign. The vast majority of states now have approved this simple registration process during the emergency.
Hello Dr. Maheu, I am a psychologist in Oregon. A client of mine is moving to Taiwan for 3 years, and has requested we continue therapy while overseas. Is it possible to treat someone living in Taiwan while I’m living in the US? I have tried reaching out to the local board here without much luck as well as to the APA.
Any thoughts of advice is very much appreciated.
Thank you!
Jill,
It most certainly can be frustrating to wait for word from a licensing board. I’d suggest a few things:
1) Send an email to your board. Colleagues report that email is the fastest way to communicate – but then again, that still can take weeks, and in some cases, months. It is important to do, however, because it establishes that you are seeking the guidance of informed peers.
2) Also, send the same letter to ASPPB – the Association for State and Provincial Psychology Boards – the association for all psychology regulators. Their CEO was our guest speaker last summer for a webinar here at TBHI. We discussed a variety of issues related to legally practicing over state lines. The fact is, it can most certainly be legal to practice internationally, but you really need to know how to do it. See our quick webinar on-demand on our list of on-demand courses here at TBHI. Be sure to select the one labeled (for psychologists). The list of TBHI’s individually available courses is here. We are available for consultation if you need more specific help.
Hi Jill – I’m curious what you found out with this situation. I have a patient now relocated in South Korea who would like to continue working together. Thank you for sharing anyhing you have learned, and thank you Dr. Maheu for the information you’ve shared thus far. – Trevor Davis
You are most welcomed.
Is it possible to treat patients in the USA with an active state license while living in Europe?
Robert,
Licensed professionals generally can offer services in the US, but there are limits by licensing boards that you may want to investigate and document. Also, other issues may be involved. For example, billing for Medicare is illegal from aboard. Enjoy your travels!
In Florida any licensed health professional can get a certificate to do teletherapy. This legislation was passed last year. There’s no charge or renewal fee. You have to have your board submit a paper verification form and you need to have a place in Florida where they can send stuff if someone complains against you. Both of these are small fees. It took me a couple of weeks to get it and that was before the pandemic. I suspect that other states will want to adopt this model in the future, especially now. No special training required and only licensed people in good standing. You can not also do a physical practice in Florida.
Karin Wandrei, LCSW
Florida Out-of-State Telehealth Provider #45
Karin,
Thank you for your comment. Yes, Florida has led the way with its 2019 progressive and wide-sweeping legislation. Many states have adopted an even more minimalistic “affidavit” process during COVID, and I hope thy follow Florida’s lead after COVID. It would be interesting to see the outcome data related to Florida’s progressive experiment. Let us know if you hear any related news.
I am a LCSW in Florida and. I was able to contact the social work board in SC so that I could see one of my patients there and was given authorization for 60 days
Debra, Thank you for letting our community know of your success.
I am a Licensed Professional Counselor (Texas) and I am living in France. Is it possible to do counseling sessions while I am here?
Cathy – Kudos to you for wanting to help. You may want to start by contacting your board in Texas, as well as the board(s) for your profession in the state(s) that you’d like to serve. If you seek insurance reimbursement, you may also want to check with the payor(s) too. There are many waivers right now, but it is always best to talk directly to the boards and the payors.
You may also want to re-read the blog above because it is regularly updated with new information that might be of help.
I practice telehealth for pediatric sleep medicine in CO. My husband and I would like to get in our RV and travel around the country. I can’t see why it would be a problem to use my “mobile office” to see patients. After all, I am licensed in CO and I am treating my patients who reside in CO. What do you think?
D. Neal, the major problem would be consistency of bandwidth. There are workarounds, and you will need to know them well. Many hotels and campgrounds say they have internet connections, but they usually are not strong enough if they work at all. It is possible though.