The rule under everything: licensed where the patient sits

Licensed where the patient sits, not where you sit

For any telehealth visit, the state that governs your license is the state where the patient is physically located when the visit happens. Not the state where you sit. Not the state where your practice is incorporated. Not the patient's mailing address or home of record. The patient's body, in a chair, in a room, in a state — that location is the one your license has to match 1Ref 1U.S. Department of Health and Human Services (2026).Licensure — Telehealth policy.The core rule that telehealth licensure is governed by the state where the patient is located at the time of service..

This is the single rule under everything else on this page, and it does not bend for convenience. A psychologist sitting in Ohio who opens a video visit with a client who has driven to Kentucky for the week needs authority to practice in Kentucky that day, not Ohio. the license that matters is the one for the state where the patient is sitting, at the moment of the visit. Every compact, registration, and exception below is a different route to holding that authority — none of them replaces it.

Why the patient's location is the one that counts

A state licenses professionals to protect the people inside its borders, so the law treats the care as happening where the patient is. When you open a session with someone sitting in another state, you are practicing your profession in that state, and its board is the authority you answer to. That is why "I'm licensed in my own state" does not settle the question 1Ref 1U.S. Department of Health and Human Services (2026).Licensure — Telehealth policy.The core rule that telehealth licensure is governed by the state where the patient is located at the time of service..

The logic is worth internalizing because it explains the edge cases before you meet them. The visit is deemed to occur at the patient's feet, not at the midpoint of the connection and not at your desk. A patient who logs in from a hotel in a third state has moved the visit to that third state. A snowbird who spends winters in a warmer state is, for those months, a patient in that state. The connection technology is irrelevant to the rule — video, phone, or secure messaging, the question is always the same: where is the person receiving care, right now?

The compacts that let you cross state lines

For several professions, an interstate compact offers a faster route to authority in the patient's state than applying for a full license there from scratch. A compact is an agreement among member states to recognize a qualifying clinician's home license through a shared privilege or an expedited application. Five matter most for a solo behavioral-health practice, and they work differently by profession.

PSYPACT lets a qualifying psychologist practice telepsychology across member states under a single authority to practice interjurisdictionally 2Ref 2PSYPACT Commission (2026).PSYPACT.That PSYPACT authorizes qualifying psychologists to practice telepsychology across member states under one authority to practice interjurisdictionally.. The Counseling Compact works the same way for licensed professional counselors: it grants a privilege to practice in member states — a recognition of your home license rather than a new one — once both your home state and the patient's state are live 3Ref 3Counseling Compact Commission (2026).Counseling Compact.That the Counseling Compact grants licensed professional counselors a privilege to practice, including telehealth, in member states.. The Social Work Licensure Compact extends the same idea to social workers as states enact and stand it up 4Ref 4Social Work Licensure Compact (2026).Social Work Licensure Compact.That the Social Work Licensure Compact creates multistate practice privileges for eligible social workers as states enact and implement it., and because it is newer, confirm the patient's state is actually operational and not merely a signatory.

Prescribers read the table differently. The Interstate Medical Licensure Compact does not hand a physician one license good everywhere; it is an expedited pathway to a full, separate license in each member state you apply to 5Ref 5Interstate Medical Licensure Compact Commission (2026).Interstate Medical Licensure Compact.That the IMLC is an expedited pathway to a full medical license in each member state, not a single multistate license.. A psychiatric-mental-health nurse practitioner has two licensure layers, and the Nurse Licensure Compact touches only the RN layer — it lets an RN or LPN hold one multistate license honored across member states 6Ref 6National Council of State Boards of Nursing (2026).NURSECOMPACT — Nurse Licensure Compact.That the Nurse Licensure Compact lets RNs and LPNs hold one multistate license honored in member states — the RN layer under a PMHNP's licensure, distinct from the narrower APRN compact., while the separate APRN compact that would carry prescriptive authority is narrower and adopted by far fewer states. Know which layer your practice actually runs on.

A compact is a privilege, not a shortcut around the rule

A compact changes the path to authority in the patient's state; it never changes the requirement to have it. Every compact still asks four things: that you hold a qualifying license in your home state, that you meet the compact's eligibility bar, that you actually obtain the privilege or complete the expedited application, and — the one solo clinicians miss — that the patient's state is a participating member.

That last condition is where plans fall apart. Compacts only reach member states, and membership is a moving target as legislatures enact and commissions bring states live. If your patient is sitting in a state that has not joined your profession's compact, the compact does nothing for you and you are back to the question the whole page started with: do you hold authority to practice in that state? For the IMLC in particular, remember you are collecting full licenses one state at a time 5Ref 5Interstate Medical Licensure Compact Commission (2026).Interstate Medical Licensure Compact.That the IMLC is an expedited pathway to a full medical license in each member state, not a single multistate license. — the compact speeds the paperwork, but each license carries its own renewal, its own fees, and its own board you answer to. Treat the privilege as a credential you maintain, not a one-time unlock.

When there's no compact, the paths that remain

If the patient's state has no compact for your profession — or you don't qualify — three paths remain: full licensure by endorsement in that state, a telehealth-specific registration where the state offers one, or simply not seeing patients located there. A growing number of states have created a limited out-of-state telehealth registration, but whether the patient's state is one of them is a question only its licensing board can answer.

Full licensure by endorsement is the durable answer: you apply to the patient's state board, transfer your credentials, and hold a real license there. It is slower and it adds a renewal cycle, but it is unambiguous. The telehealth-registration path is faster where it exists — a limited permit that lets an out-of-state clinician treat that state's residents by telehealth without full licensure — but the eligibility, the scope, and even whether it exists vary by state, so confirm it with the patient's-state board before you schedule, not after. What you cannot do is treat the absence of a rule as permission. If you cannot establish authority in the patient's state through any of these paths, the honest move is to decline or refer, not to proceed and hope.

Licensure answers 'may I,' not 'will I be paid'

Being licensed in the patient's state answers whether you may treat them; whether an insurer pays is a separate question with its own rules. Payers set their own telehealth policies on which codes, modifiers, and place-of-service values they accept, and Medicare's telehealth rules are their own layer on top of your license. Clearing the licensure question does not clear the payment question.

For Medicare, several behavioral-health telehealth provisions are permanent: the patient's home can serve as the originating site, and audio-only visits are payable when the patient can't or won't use video 7Ref 7U.S. Department of Health and Human Services (2026).Telehealth policy.Which Medicare telehealth flexibilities are permanent (behavioral health, including audio-only where video is unavailable) versus temporary, as of July 2026.. Those permanent behavioral-health flexibilities sit alongside broader telehealth flexibilities whose status has been repeatedly extended rather than made permanent, so treat the non-behavioral-health rules as volatile and check their current status before you rely on them — as of July 2026, the split between permanent and temporary is the thing to verify 7Ref 7U.S. Department of Health and Human Services (2026).Telehealth policy.Which Medicare telehealth flexibilities are permanent (behavioral health, including audio-only where video is unavailable) versus temporary, as of July 2026.. The Medicare Learning Network's telehealth booklet is the primary reference for the originating-site rules, the audio-only conditions, and any in-person-visit requirements attached to behavioral-health telehealth 8Ref 8Centers for Medicare & Medicaid Services (2025).Telehealth Services.Medicare telehealth specifics — the home as originating site, audio-only conditions, and in-person-visit requirements for behavioral-health telehealth.. Synchronous video visits, audio-only visits, and asynchronous e-visits billed under 99421–99423 are three different billing lanes with three different rule sets — don't let a licensure green light blur them together.

Before every visit, confirm where the patient actually is

Because the rule attaches to the patient's physical location at the moment of care, you confirm that location at the start of every visit — not once at intake, but every time. A patient who traveled, moved, or is calling from a second home has changed which state's authority applies, and you often can't tell from the screen. Ask where they are, and document the answer.

Build the location check into the opening of the session the way you build in identity verification — a plain question, a documented answer, before clinical work begins. If the patient turns out to be in a state where you hold no authority, the visit cannot proceed as a routine appointment; reschedule for when they're back in a state you're licensed in, or, if there is an acute safety concern, help them reach local emergency services by calling 911 or the 988 Suicide and Crisis Lifeline. Plan for the dropped call, too: if the connection fails, you need the patient's location and a callback number to re-establish care safely. And take licensure seriously as a billing question — a claim for a visit you weren't licensed to provide in the patient's state is exposed to recoupment as an overpayment, much like billing during a lapse of your state licensure. Practicing without authority where the patient sits is not a paperwork foot-fault; it is the practice of a licensed profession without a license, with all the board and payer consequences that carries.

Your first move: map the states your patients actually sit in

Before you worry about compacts, list the states your patients are physically in. For most solo practices that's one or two, and the whole problem collapses to holding the right authority in those. Practices that market across state lines, or that inherited clients who later moved, accumulate a longer list — and every state on it is a separate licensure obligation you either meet or stop serving.

Run the list once and keep it current. For each state, note which authority you rely on — home license, a compact privilege, an endorsement license, or a telehealth registration — and its renewal date, because authority you let lapse is authority you no longer have. Where a compact covers the state, confirm both your home state and the patient's state are live members, not just signatories, since that status changes as commissions add states. Where nothing covers it, decide deliberately: pursue licensure there or route those patients elsewhere. The failure mode is drift — a client relocates, mentions it in passing, and three months of visits later you're practicing in a state you never authorized. A standing habit of asking where the patient is, every visit, is what catches the drift before it becomes a board matter.