Good-Faith Exam Requirements by State (incl. Telehealth)

A good-faith exam establishes a provider-patient relationship and documents clinical judgment that the patient is a suitable candidate for treatment. At minimum, the exam should include:

• Patient history: medical and surgical history, current medications (especially anticoagulants, NSAIDs, immunosuppressants), allergies, and prior adverse reactions to injectables or topicals
• Physical assessment: visual inspection of the treatment area, skin type/condition, facial anatomy, and any contraindications (active infection, severe skin disease, pregnancy/nursing status for certain agents)
• Informed consent: discussion of risks, benefits, alternatives, realistic outcomes, and downtime
• Documentation: contemporaneous notes linking clinical findings to the treatment plan

The exam does not require a full physical or laboratory work-up in most states, but it must be specific to the proposed treatment. A cursory "looks good" does not meet the standard. State boards and payers increasingly scrutinize whether the documented exam supports the treatment decision. If a patient presents with active herpes simplex and receives Botox anyway, the exam record must explain why (e.g., prophylactic antivirals prescribed). Absence of that reasoning is a red flag.

Physicians (MDs, DOs) can always perform a GFE and delegate treatment to licensed nurses or PAs under supervision.

Nurse Practitioners (NPs) and Physician Assistants (PAs) have state-dependent autonomy:

• Independent practice states (CA, TX, NY, FL, and others): NPs and PAs can conduct exams and prescribe/administer injectables without physician co-signature, provided they meet state licensing and continuing-education requirements
• Collaborative/supervised states: NPs and PAs must work under a physician's protocol or standing order; the physician may not need to be present but must review and approve the exam and treatment plan
• Restrictive states: Some states require physician presence or direct supervision for any injectable administration

Registered Nurses (RNs) and Licensed Estheticians cannot independently perform a GFE or prescribe; they administer under a provider's order. However, some states allow RNs to conduct a preliminary assessment (vital signs, history) that feeds into a physician's exam.

The Corporate Practice of Medicine doctrine (enforced in CA, TX, and others) further restricts who can own and operate an aesthetic practice. In these states, a non-physician cannot own a medical spa; a physician must be the owner or supervising partner. This affects your hiring and delegation structure.

Telehealth GFEs for injectables remain highly restricted. Most state medical boards require in-person exams for aesthetic injectables because visual assessment of facial anatomy, skin texture, and asymmetry is considered essential.

States permitting remote GFEs (limited list):

• California: NPs and PAs can conduct telehealth exams for Botox/fillers under specific protocols; physician oversight required
• Texas: Telehealth exams allowed under established provider-patient relationship; some restrictions on first-time patients
• Florida: Permits telehealth for established patients; new patients typically require in-person visit

Most states: Require in-person exam. Even during COVID, state boards clarified that aesthetic injectables do not qualify for remote-only prescribing.

Practical implication: If you operate in multiple states, you cannot assume a telehealth consultation in one state satisfies another's requirement. A patient who had a video consult in CA may still need an in-person exam before treatment in FL. Document the exam location and modality in your records. Some practices use hybrid models: telehealth for history/consent, in-person for physical exam and injection.

State boards and payers (especially Medicare/Medicaid) audit GFE documentation closely. Weak records are the leading cause of compliance findings.

Minimum documentation:

• Date, time, and location of exam (in-person vs. telehealth)
• Examiner credentials (name, license number, title)
• Patient history: relevant medical/surgical history, medications, allergies
• Physical findings: specific observations (e.g., "moderate glabellar lines, no active skin infection, symmetric facial structure")
• Contraindications assessment: documented review and clearance
• Informed consent: signed or electronically acknowledged
• Treatment plan: specific product, dose, injection sites, rationale

Red flags that trigger audits:

• Templated notes with no patient-specific detail
• Exam performed by non-credentialed staff with no physician review
• Telehealth exam in a state requiring in-person evaluation
• Exam date after treatment date (retroactive documentation)
• No documentation of informed consent

Insurance and board enforcement: Medicare Administrative Contractors (MACs) deny claims lacking adequate GFE documentation. State boards issue citations for scope-of-practice violations (e.g., RN conducting exam without provider order). Maintain exams in a separate, easily retrievable section of the patient record.

GFE and telehealth rules evolve. Verify your state's current standard through:

• State Medical Board: Most post scope-of-practice guidelines and telehealth policies online. Search "[State] medical board aesthetic injectables" or "telehealth policy"
• State Nursing Board: For NP/RN scope clarification
• State PA Board: For PA autonomy and supervision requirements
• Professional societies: The American Society of Plastic Surgeons (ASPS), American Academy of Dermatology (AAD), and American Society of Aesthetic Plastic Surgeons (ASAPS) publish state-specific practice advisories
• Your malpractice carrier: Often provides state-specific compliance summaries
• Legal counsel: For practices operating in multiple states or with complex staffing models, a healthcare attorney familiar with your state's Corporate Practice of Medicine doctrine is essential

Do not rely on manufacturer guidance (e.g., Allergan's training materials) as a substitute for state law; manufacturers provide general best practices, not state-specific legal requirements. Update your protocols annually or whenever your state board issues new guidance.

Pitfall 1: Delegating exams to non-credentialed staff. RNs and estheticians cannot independently conduct GFEs. Solution: Establish a clear protocol where a licensed provider (MD, DO, NP, or PA per your state) reviews and documents the exam.

Pitfall 2: Telehealth in restrictive states. Offering remote consultations in states that require in-person exams exposes you to board complaints and insurance denials. Solution: Clarify your state's telehealth policy and enforce in-person exams where required. If you operate a multi-state practice, use geographic IP blocking or explicit disclaimers.

Pitfall 3: Inadequate informed consent. Verbal consent is not enough; document it. Solution: Use written or electronic consent forms specific to each treatment (Botox, filler, RF microneedling, etc.) and retain signed copies.

Pitfall 4: Exam-treatment timing gaps. Exams valid for 6–12 months vary by state and payer. Performing treatment 18 months after an exam may violate your state's standard. Solution: Establish a policy (e.g., "exams valid for 12 months") and flag charts for re-exam when approaching the limit.

Pitfall 5: Misaligned credentials and scope. Hiring an NP from an independent-practice state and deploying them in a supervised state without adjusting protocols causes violations. Solution: Map each staff member's credentials to your state's scope and document the supervision structure.