Telemedicine Clearance: What Still Qualifies

Telemedicine can still be used for good faith exams in many states. The virtual format does not lower the clinical standard.

A compliant virtual encounter should allow the authorized provider to gather enough information to determine whether the patient is an appropriate candidate for treatment.

Medical Director Co.’s current virtual good faith exam guidance emphasizes live clinical evaluation rather than relying only on forms, texts, or automated questionnaires. State requirements can still differ, so clinics should confirm what their jurisdiction permits before making virtual clearance the default.

A virtual workflow should address:

• Provider authorization: The person performing the exam should have the license and authority required for the patient’s state.
• Patient location: Staff should document where the patient is physically located during the encounter.
• Clinical history: The provider should review relevant medical history, medications, allergies, contraindications, and current concerns.
• Actual clinical assessment: The encounter should give the provider enough information to make an individualized treatment decision.
• Treatment decision: The record should show whether the patient was approved, declined, or referred for further evaluation.
• Documentation: The virtual encounter should be documented as a clinical visit rather than reduced to a completed intake form.

Federal telehealth guidance also continues to treat licensure as state-based. HHS notes that providers generally must be licensed or legally permitted to practice in the state where the patient is located.

For a deeper breakdown, see Can a Good Faith Exam Be Done Virtually?.

Where Med Spas Get Good Faith Exams Wrong

A clinic can schedule the exam correctly and still create a compliance problem in the chart. One recurring issue is treating an intake questionnaire as if it were the medical evaluation itself.

A patient may complete questions about medications, allergies, previous procedures, and medical history before the visit. That information is useful, but it does not replace the provider’s clinical assessment and documented treatment decision.

Medical Director Co.’s documentation guidance recommends treating the good faith exam like another clinical encounter. The record should show the history reviewed, relevant findings, assessment, and plan rather than only a checked box that says the patient is “cleared.”

Other common gaps include:

• No clear treatment decision: The chart contains intake information but does not show why treatment was approved.
• Generic notes: Every patient’s record uses nearly identical language without documenting relevant individual findings.
• Missing provider information: It is unclear who actually performed the evaluation and made the clinical decision.
• No link between the exam and treatment: The record does not clearly identify the treatment the patient was evaluated to receive.
• Incomplete telehealth documentation: The clinic does not document that the encounter occurred remotely or where the patient was located.
• No renewal process: The clinic has no system for identifying when a new evaluation may be needed.

The goal is not more paperwork for its own sake. The chart should make the clinical decision understandable to someone reviewing it later.

Update Your Good Faith Exam Documentation for 2026

Clinics with an existing process do not necessarily need to rebuild it from the beginning. They should confirm that the current workflow still matches their services, providers, and states.

Start with the forms and templates your team actually uses.

Confirm the Patient Record Captures the Clinical Encounter

The record should contain enough information to show that a qualified provider evaluated the patient before treatment.

Review whether your template captures:

• Relevant medical history;
• Medications and allergies;
• Contraindications;
• Treatment being considered;
• Relevant clinical findings;
• Assessment of treatment suitability;
• Treatment approval or denial;
• Provider name and credentials; and
• The date of the evaluation.

Medical Director Co.’s current charting guidance recommends documenting the history, findings, assessment, and treatment plan that support the decision.

Review Telemedicine Fields

If exams are performed remotely, the documentation should reflect the remote encounter.

Check whether the record captures patient location, provider identity, the method of communication, and any other information required by the applicable state.

HHS telehealth guidance also recommends documenting telehealth encounters and maintaining appropriate clinical records.

Review the Workflow When Services Change

Adding a new service can change what needs to happen before treatment. A process designed around injectables may not automatically address IV hydration, prescription weight management, hormone therapy, or another treatment category.

Update your GFE process when the clinic adds:

• A new treatment;
• A new prescription medication;
• A new provider type;
• Another location; or
• Another state.

The exam process should follow the care being provided today, not the care the clinic offered when the template was first created.