“Telehealth Is Allowed Right Now” Is Not an Authority

A psychiatrist has three telemedicine visits in one afternoon and signs three controlled-substance prescriptions.

The first is a stimulant for a patient the psychiatrist has never examined in person. The footing is the Fourth Temporary Extension.

The second is a stimulant for a patient the same psychiatrist examined in person two years ago. The footing is the Ryan Haight in-person evaluation. No flexibility is required.

The third is buprenorphine for opioid use disorder under 21 C.F.R. § 1306.51. The footing is a final rule that became effective December 31, 2025.

The EHR workflow is the same. The three notes are identical. Nothing in the chart names the authority, the conditions that authority imposes, or the date that authority expires.

This fictional composite is not a patient case. It is three prescriptions that share a note template and no named authority.

Three defensible prescriptions that are indistinguishable, on paper, from three indefensible ones.

Sources reviewed August 17, 2026: U.S. federal baseline, not a state-law conclusion or nationwide standard of care.

21 U.S.C. § 829(e)(1) provides that no controlled substance that is a prescription drug “may be delivered, distributed, or dispensed by means of the Internet without a valid prescription.” A “valid prescription” is issued for a legitimate medical purpose in the usual course of professional practice by a practitioner who has conducted at least one in-person medical evaluation of the patient, or by a covering practitioner. An “in-person medical evaluation” is conducted with the patient in the physical presence of the practitioner. One such evaluation does not, by itself, establish legitimate medical purpose.

That in-person rule does not apply to a practitioner engaged in the “practice of telemedicine,” 21 U.S.C. § 829(e)(3)(A). “Practice of telemedicine” is defined in 21 U.S.C. § 802(54): the practice of medicine in accordance with applicable Federal and State laws by a practitioner (other than a pharmacist) remote from the patient, using a telecommunications system referred to in 42 U.S.C. § 1395m(m), under one of the lettered categories — including joint Attorney General / Secretary regulation, § 802(54)(G).

The current telemedicine authorities are exceptions layered on that baseline. They are not a substitute for it.

A documented qualifying in-person evaluation by the prescribing practitioner does not need a flexibility. Once that evaluation has occurred, the Ryan Haight remote-prescribing restriction no longer applies to that practitioner-patient relationship, so long as the prescription is issued for a legitimate medical purpose in the usual course of professional practice and in compliance with other applicable federal and state requirements (90 FR 61302). That footing does not expire. The Fourth Temporary Extension expires at the end of December 31, 2026. Those are different clocks.

“Together, the Two Final Rules and this temporary rule describe three separate and distinct sets of authorities for telemedicine prescribing, and each imposes a unique set of requirements with respect to prescribing done pursuant to it” (preamble § V, 90 FR 61304). A practitioner may issue a prescription under the temporary rule even if that prescription could also be issued under one or both of the Two Final Rules. The Final Rule requirements apply only if the prescription is issued pursuant to that Final Rule. The temporary rule imposes fewer requirements (90 FR 61304).

The record has to name which one.

Status: temporary; expires at the end of December 31, 2026 (operative § 1307.41(a), 90 FR 61306).

Citation: 90 Fed. Reg. 61301 (Dec. 31, 2025) (temporary rule); pages 61301–61306; FR Doc. 2025-24123.

Who qualifies. All DEA-registered practitioners. Schedules II–V. No in-person evaluation. Authorization runs May 12, 2023 through December 31, 2026. No November 11, 2023 relationship cutoff.

Conditions. § 1307.41(c): (1) issued for a legitimate medical purpose by a practitioner acting in the usual course of professional practice; (2) issued pursuant to a communication using an interactive telecommunications system referred to in 42 C.F.R. § 410.78(a)(3); (3) the practitioner is authorized under 21 C.F.R. § 1301.13(e)(1)(iv) to prescribe that basic class, or is exempt under 21 U.S.C. § 822(d); (4) consistent with 21 C.F.R. part 1306. The Fourth Temporary Rule’s amendatory text does not restate a separate audio-only opioid-use-disorder carve-out; it points to § 410.78(a)(3). DEA’s preamble background (90 FR 61302) and press materials describe the flexibilities’ audio-only as OUD-scoped, while the operative text points to § 410.78(a)(3); treat non-OUD audio-only under Lane 1 as HOLD, not PASS.

What the record should show. That this prescription stands on § 1307.41; that the encounter used an interactive telecommunications system as referred to in § 410.78(a)(3); patient location and prescriber location; and the expiration date.

Clock source. § 1307.41(a), 90 FR 61306: “This section is in effect until the end of the day December 31, 2026. The authorization granted in paragraph (b) of this section expires at the end of December 31, 2026.” DATES: effective January 1, 2026 through December 31, 2026.

The prescription must still be issued “in accordance with applicable Federal and State laws” (90 FR 61303).

Status: effective (as of December 31, 2025).

Citation: Expansion of Buprenorphine Treatment via Telemedicine Encounter, 90 Fed. Reg. 6504 (Jan. 17, 2025) (FR Doc. 2025-01049), pages 6504–6523; delayed to March 21, 2025 by 90 FR 9841; delayed to December 31, 2025 by 90 FR 13410 (no change to substance, 90 FR 13411). Confirmed at 90 FR 61304.

Who qualifies. A practitioner authorized under 21 C.F.R. §§ 1301.11, 1301.12(a), and 1301.13(e)(1)(iv) to prescribe the basic class specified on the prescription, or exempt from registration under 21 U.S.C. § 822(d). No DATA-waiver residue.

What may be prescribed. Three conjunctive filters in the opening grant: (i) schedule III–V, and (ii) listed in 42 C.F.R. § 8.12(h)(2), and (iii) FDA-approved for treatment of opioid use disorder. § 8.12(h)(2) currently lists methadone; buprenorphine and buprenorphine combination products approved for OUD; and naltrexone. Methadone is schedule II. Naltrexone is not a controlled substance. Preamble n.21, 90 FR 6506: “Currently, the only schedule III-V controlled substance narcotic drug approved by the FDA for the treatment of OUD is buprenorphine.” The operative text is the filter, not a buprenorphine-only grant. Prescriptions issued pursuant to this section may be issued only for the treatment of OUD, § 1306.51(b)(5). No schedule II authority under this section. No OTP-enrollment condition.

Modality. “an interactive telecommunications system, including an audio-only telecommunications system, as described in 42 CFR 410.78(a)(3).” That definition is audio and video by default. Audio-only is available for a telehealth service furnished to a patient in their home if the distant-site practitioner is technically capable of using audio-video equipment and the patient is not capable of, or does not consent to, the use of video technology. The Medicare claim-modifier sentences inside § 410.78(a)(3) are not an independent DEA duty. The section does not require the record to state whether the encounter was audio-only or audio-video. No mandatory in-person follow-up during the six calendar months.

Conditions.

(1) The prescribing practitioner must be authorized to access the PDMP of the state in which the patient is located at the time of the encounter; must review controlled-substance prescriptions issued to the patient in the last year, or the entire available period if less than one year; must annotate the date and time of that review in the patient’s electronic health record (EHR) or paper record; and must conduct the review, or an attempted review, before issuing the prescription.

(2) Prescriptions may be issued pursuant to this section for a period not to exceed six calendar months beginning on the date the first prescription is issued. That is a time period, not a quantity cap. The SUMMARY’s “initial six-month supply” language (90 FR 6504) does not control. No in-person visit is required during those six calendar months. After that period, additional prescriptions for schedule III–V controlled substances approved by the FDA for treatment of OUD may be issued only after that same prescribing practitioner has conducted at least one in-person medical evaluation as defined in 21 U.S.C. § 829(e)(2)(B), or as otherwise authorized by § 829(e), including another form of telemedicine under § 802(54).

(3) If PDMP data is inaccessible or unavailable, annotate in the patient’s EHR or paper record the date and time of the attempt and the reason the data could not be reviewed. A seven-day supply may be prescribed; another PDMP review is required before another seven-day supply. Each time the PDMP is reviewed or attempted to be reviewed, the date and time must be annotated in the patient’s EHR. Seven-day supplies count toward the six-calendar-month clock. The same paragraph says “EHR or paper record” and later “the patient’s EHR.” Both sentences are in the regulation.

(4) Pharmacy identification is a pharmacist duty: the pharmacist shall verify the identity of the patient before filling, with a state or Federal government-issued photographic identification card or other form of identification, which may be presented by any qualifying “ultimate user” under 21 U.S.C. § 802(27).

(5) Indication lock: OUD only.

(6) Registration as above.

(7) The issuance otherwise complies with part 1306.

What the record should show. That this prescription stands on § 1306.51; patient location (the fact that selects the PDMP); PDMP review or attempted-review date, time, and, if down, the reason; the date the first prescription under this section was issued; the OUD indication; and the date the six-calendar-month period ends.

Clock source. § 1306.51(b)(2): six calendar months from the date the first prescription under this section is issued. The section itself has no sunset. The authority became effective December 31, 2025 (90 FR 13410).

A buprenorphine prescription that could be issued under this section may instead be issued under Lane 1. The Final Rule’s conditions apply only if the prescription is issued pursuant to the Final Rule (90 FR 61304). The record has to say which.

Status: effective (as of December 31, 2025).

Citation: Continuity of Care via Telemedicine for Veterans Affairs Patients, 90 Fed. Reg. 6523 (Jan. 17, 2025) (FR Doc. 2025-01044), pages 6523–6540; same delay chain as Lane 2 (90 FR 9841; 90 FR 13410). Most readers are not VA practitioners. The lane completes DEA’s three-authority frame.

Who qualifies. A VA employee or contractor acting in the scope of that employment or contract, registered under 21 U.S.C. § 823(g) in any state or using the registration of a VA hospital or clinic. Excluded: a contracted practitioner located outside a VA facility or clinic providing care via the community care network, or conducting disability compensation evaluations.

Patient. A VA patient who has previously received, at any time, an in-person medical evaluation by any VA practitioner who then had prescribing authority, or would reasonably be expected to have it based on credentials or organizational role. No recency clock. The prescribing VA practitioner need not be the examiner.

Substances. “controlled substance(s).” No schedule III–V lock. No OUD lock.

Modality. Via the practice of telemedicine under 21 C.F.R. § 1300.04(i)(7). The section does not contain an express audio-only clause.

Conditions (summary). Legitimate medical purpose, usual course, “in accordance with applicable Federal and State law(s).” Before prescribing, review both the VA EHR (including the VA internal prescription database) and the PDMP of the state in which the patient is located, if that state has a PDMP, for the prior twelve months or the entire available period. If either database is unavailable or non-operational: 7-day supply only, then complete the reviews to continue. If no PDMP exists in the patient’s state: review the VA internal prescription database; a prescription may extend beyond 7 days. Annotate attempts, nonexistence of a PDMP, and failed access in the VA EHR. No six-month cap. No pharmacist photo-ID duty in this section.

Clock source. No six-month cap. Authority effective December 31, 2025 (90 FR 13410).

Special Registrations for Telemedicine and Limited State Telemedicine Registrations, 90 Fed. Reg. 6541 (Jan. 17, 2025) (proposed rule); pages 6541–6598; FR Doc. 2025-01099; Docket DEA-407; RIN 1117-AB40. Comment period closed March 18, 2025, 11:59 p.m. ET (90 FR 6541 DATES). Status: proposed (not current law). This article does not treat the proposal as operative and does not predict finalization.

The NPRM would authorize three types of Special Registration (90 FR 6542): (1) Telemedicine Prescribing Registration — schedule III–V; (2) Advanced Telemedicine Prescribing Registration — schedule II–V, psychiatrists first-listed (90 FR 6549–6550); (3) Telemedicine Platform Registration — platforms that dispense II–V through a clinician holding (1) or (2). State Telemedicine Registration is ancillary, not a fourth type (90 FR 6543).

Proposed practice standards — all proposed, none current: nationwide PDMP review after three years, with an interim three-category check (90 FR 6543, 6554; proposed § 1306.43 at 6597); audio-video at every encounter, with an OUD audio-only exception if the relationship was initiated audio-video (90 FR 6554–6556; proposed § 1306.44 at 6597–6598); schedule II limited to Advanced registration plus specialty, with an anticipated same-state and/or 50 percent cap (90 FR 6556; proposed § 1306.45 at 6598); DEA reporting by pharmacies monthly and by special registrants annually (90 FR 6557–6560, 6596–6597); identity verification by photo ID at the first encounter, renewed every two years (proposed § 1304.04(i), 90 FR 6596); record retention of at least two years (90 FR 6558, 6589, 6596).

These proposed elements preview what a defensible record already looks like. A practice can adopt the documentation without adopting the speculation. They are not current obligations.

The Fourth Temporary Rule’s legal-authority discussion requires that the practice of telemedicine be “in accordance with applicable Federal and State laws” (90 FR 61303). § 1306.52(a)(4) restates the same clause. § 1306.51 does not; state-law limits still sit in the CSA and part 1306 baseline.

This is not a 50-state chart. The categories that change the record are: state or jurisdiction telehealth-prescribing statutes; state or jurisdiction in-person-examination requirements; state or jurisdiction PDMP mandates; prescriber-location rules; patient-location rules; and the dispensing pharmacy’s state or jurisdiction.

In a multi-state or multi-jurisdiction practice the applicable rule set changes with the patient’s location at the time of the encounter. Record both locations.

For CSA purposes, 21 U.S.C. § 802(26) provides: The term “State” means a State of the United States, the District of Columbia, and any commonwealth, territory, or possession of the United States. That definition applies to the telemedicine sections because 21 C.F.R. § 1300.01(a) incorporates undefined terms from 21 U.S.C. § 802; § 1300.01 has no standalone definition of “State.” A patient located in the District of Columbia, Puerto Rico, Guam, or the U.S. Virgin Islands at the time of the encounter selects that jurisdiction’s telehealth-prescribing rules and that jurisdiction’s PDMP; where no PDMP exists, document its nonexistence the way § 1306.52 models it.

Alabama is one illustration of a jurisdiction refresh interval, not coverage. Ala. Code § 34-24-704(b)(1) permits a controlled-substance prescription as a result of telehealth medical services only if the visit uses synchronous audio or audio-visual communication on HIPAA-compliant equipment with the prescriber responsible for the prescription, the prescriber has had at least one in-person encounter with the patient within the preceding 12 months, and a legitimate medical purpose was established within the preceding 12 months. The federal in-person footing is indefinite (90 FR 61302); Alabama’s is a rolling 12-month refresh. The composite’s second prescription — an in-person examination two years ago — PASSES on the federal footing and HOLDS under § 34-24-704(b)(1)b if the patient is located in Alabama. Subsection (b) does not apply in an in-patient setting, § 34-24-704(b)(2). An emergency exemption exists at § 34-24-704(c), “as further defined by rule” of the Board and Commission. The mental-health-services exception in § 34-24-703(f)(5) attaches to that section’s visit-frequency rule, not to the controlled-substance rule in § 34-24-704(b).

The authority relied on. The modality — audio-video or audio-only — and which of the three authorities, or the in-person footing, permits that modality for this prescription. Patient location and prescriber location (state, DC, or U.S. territory). The in-person examination date and the examiner, if any. The PDMP check required by the authority relied on and by the applicable state or jurisdiction rule. Identity verification that the applicable authority actually imposes — under § 1306.51, a pharmacist duty before fill, not a prescriber photo-ID duty. The authority’s expiration date and the re-review trigger.

Operational and documentation failures, not a conclusion that any prescription was unlawful. Correcting them does not create authority.

“Telehealth visit” is a modality, not an authority.

No December 31, 2026 re-review trigger.

The in-person footing is a date and an examiner, not a checkbox.

Lane 1 points to § 410.78(a)(3) without restating a separate audio-only grant. Lane 2 includes audio-only as described in that definition, including the home, capability, and consent clauses. Lane 3 has no express audio-only clause.

Lane 2 is III–V and OUD-locked. Lane 1 and Lane 3 are not.

The patient’s location selects the state-or-jurisdiction rule set.

The Special Registration framework is proposed (not current law).

The fact that selects the state-or-jurisdiction rule set, and the Lane 2 PDMP, is missing.

Download the Telemedicine Controlled-Substance Authority Record (PDF) (383 KB)

If any answer is unknown, do not treat the prescription as standing on a named authority. Name an owner.

Educational Disclaimer: The Psychiatric Record provides general educational information for psychiatric and mental-health professionals. Content does not constitute medical, legal, regulatory, compliance, billing, or other professional advice; does not establish a standard of care; and is not a substitute for independent professional judgment. Requirements and appropriate practices may vary by jurisdiction and circumstance. Verify current authoritative sources.

This article does not determine whether any prescription may be issued, and the companion worksheet does not create prescribing authority or satisfy any registration requirement.