Short answer: Asynchronous telehealth is care where the patient and provider do not meet live. The patient completes a secure intake, uploads photos or other information, and a licensed provider reviews it later and responds through the platform. It fits many cash-pay categories, but some states require a live audio or video visit to establish care, and controlled substances follow separate federal DEA rules.
If you are building a digital clinic, asynchronous telehealth is probably the care model you have heard about most. It is how patients can start care at 11 at night without booking an appointment, and how a small provider team can review many intakes in a day. It is also the part of telehealth where founders most often get the rules wrong, because whether async is allowed depends on the patient’s state, the treatment and the provider’s clinical judgment.
This guide explains how async visits work, how async vs sync telehealth compares, where state and federal rules require a live visit, how controlled substance rules apply at the time of writing, and how to decide when async fits your brand.
What is asynchronous telehealth?
Telehealth.HHS.gov, the federal telehealth resource from the U.S. Department of Health and Human Services, describes asynchronous telehealth as care where health information is shared at different points in time, rather than in a live conversation. It is often called store and forward telehealth, because information is captured, stored and forwarded to a provider for review. You will also see the terms async telemedicine and async care.
In a digital clinic, an async visit usually looks like this: a patient answers a structured medical questionnaire, shares photos or prior records if needed, signs consents and pays. A licensed provider then reviews the intake, asks follow-up questions through secure messaging if something is unclear, and decides whether a treatment is appropriate. If the provider prescribes, the prescription goes electronically to a licensed pharmacy.
The key point for founders: async is a way of delivering care, not a shortcut around it. The provider still evaluates the patient, still owns the clinical decision and can always escalate to a live visit or decline to treat.
Async vs sync telehealth: what is the difference?
Synchronous telehealth is live, real-time care over video or, in some cases, audio only. Asynchronous telehealth happens on each person’s own schedule. Most digital clinics use both, with async as the default and live visits where the law, the treatment or the provider requires one.
| Factor | Asynchronous (store and forward) | Synchronous (live video or audio) |
|---|---|---|
| How it works | Patient submits intake and information, provider reviews later | Patient and provider meet in real time |
| Scheduling | No appointment needed | Appointment or on-demand queue |
| Patient experience | Convenient, private, done on the patient’s time | Personal, allows real-time questions |
| Provider workflow | Review queue, messaging, follow-up questions | Calendar blocks, video platform, visit notes |
| Where it may not be allowed | States that require a live interaction to establish care, many controlled substances, some complex cases | Generally allowed where telehealth is allowed, subject to state rules |
| Common uses | Refill check-ins, photo-based skin and hair review, many cash-pay programs | First visits in states that require them, controlled substances, complex histories |
How async visits work in a digital clinic, step by step
- Eligibility and state check. The patient confirms their location first, because providers must be licensed in the state where the patient is located. The platform then applies that state’s rules, including whether a live visit is required.
- Structured intake. The patient completes a medical questionnaire covering history, medications, allergies, contraindications and goals. Good intakes use branching logic so the right questions appear for each answer.
- Identity verification and consent. The patient verifies identity and signs telehealth consent, privacy notices and treatment-specific consents.
- Supporting information. Depending on the program, the patient may upload photos, prior lab results or records, or be routed to new labs. See our guide on how to add lab testing to telehealth.
- Provider review. A licensed provider reviews everything in one chart. The provider can approve, decline, request more information or require a live video visit.
- Secure messaging. The provider and patient exchange follow-up questions through the platform, and every message becomes part of the record.
- Prescription and fulfillment. If treatment is appropriate, the provider sends the prescription to a licensed pharmacy that ships to the patient. Our guide What Is a 503A Pharmacy? explains the compounding side.
- Ongoing care. Refills, check-in questionnaires and messaging keep care going, with escalation to a live visit whenever the provider needs one.
Where asynchronous telehealth is not allowed: state rules
There is no single national rule for async telemedicine. Each state sets its own standard for how a provider-patient relationship can be established over telehealth, and those rules are enforced by state medical, nursing and pharmacy boards. That is why an async model that works in one state may need a live visit in the next.
Questionnaire-only prescribing
Many states say a provider cannot prescribe based solely on an online questionnaire. According to the Center for Connected Health Policy (CCHP), which tracks state telehealth law, examples at the time of writing include Alaska, which bars prescribing in response to an Internet questionnaire or email without a prior relationship, and Arkansas, which says a professional relationship cannot be established only through an Internet questionnaire, email, patient-generated history, text messaging or fax. Arkansas allows real-time audio and visual telemedicine as an alternative to an in-person exam.
These rules do not always ban async care outright. In some states, async tools can support care once a relationship has been properly established, or a detailed intake reviewed by a provider may meet the standard. The details matter, and they change.
Rules that vary by treatment
States can also set different rules for different treatments. Controlled substances almost always carry stricter requirements, some states set specific rules for certain medication categories, and some professional boards issue their own telehealth standards for nurse practitioners or physician assistants. Your provider network and your healthcare attorney should map each state and each product before you launch there.
How to handle state variation
- Build a state matrix. For each state you serve, record whether async is permitted to establish care, whether a live visit is required and for which products.
- Let the platform route automatically. The patient’s state should decide whether they flow to async review or to a scheduled video visit.
- Recheck on a schedule. State telehealth laws change every legislative session. CCHP publishes state-by-state summaries that are a useful starting point, but your counsel should confirm current law.
- Document the standard of care. Providers should record why async was appropriate for each patient.
Our telehealth compliance checklist covers state licensing and other items to confirm before launch.
Controlled substances: Ryan Haight and the DEA telemedicine flexibilities
Controlled substances follow federal rules on top of state law. The Ryan Haight Online Pharmacy Consumer Protection Act of 2008 generally requires at least one in-person medical evaluation before a practitioner prescribes a controlled substance over the internet, with limited exceptions defined as the practice of telemedicine.
During the COVID-19 public health emergency, the Drug Enforcement Administration (DEA) and HHS allowed DEA-registered practitioners to prescribe Schedule II through V controlled substances through telemedicine without a prior in-person visit. Those flexibilities have been extended several times. At the time of writing, the fourth temporary extension, published in the Federal Register on December 31, 2025, keeps the full set of flexibilities in place through December 31, 2026.
Two details matter for an async model. First, the flexibilities are built around real-time telemedicine, generally a two-way audio and video interaction, with audio-only permitted in limited cases, such as opioid use disorder treatment. They do not turn a questionnaire into a valid basis for a controlled substance prescription. Second, the flexibilities are temporary. DEA proposed a special registration framework for telemedicine in January 2025, and reports in August 2026 indicated a final rule had been sent for White House review, but the final requirements were not public at the time of writing.
What this means for founders:
- Plan controlled substance programs around live visits. Testosterone, for example, is a Schedule III controlled substance. Our guide on how to start a TRT digital clinic covers that category.
- Watch the December 31, 2026 date. Know what your program will need if the flexibilities end or are replaced by a permanent rule.
- Remember state law still applies. A state can be stricter than the federal flexibilities.
- Verify before you build. Check the DEA and HHS pages and have a healthcare attorney confirm current rules for your formulary.
When asynchronous telehealth fits, and when it does not
Async works best when a provider can safely evaluate the patient from a well-built intake, with a clear path to a live visit when needed.
Where async often fits
- Non-controlled prescription categories where state law permits async care
- Photo-based reviews, such as many skin and hair concerns
- Refill check-ins and follow-up questionnaires for established patients
- Programs where labs and wearable data give the provider objective information to review
Where a live visit is usually needed
- States that require real-time audio or video to establish care
- Controlled substances, under current federal and state rules
- Complex histories, red-flag intake answers or unclear information
- Any time the provider decides a live conversation is clinically appropriate
Many brands run a hybrid: async by default, with automatic routing to video by state, product or intake answer. Categories like weight management often use this model.
What makes an async telemedicine program work well
- A clinically sound intake. Built with licensed providers, with contraindication screening and branching logic.
- Clear escalation paths. Providers can move any patient to video with one step, and urgent symptoms route the patient to emergency care.
- Fast, clear messaging. Patients should know when to expect a response and how to reach support.
- One chart. Intake, photos, labs, messages and prescriptions in one record for the provider.
- HIPAA safeguards. Every vendor that handles protected health information should sign a business associate agreement. See what makes a telehealth platform HIPAA compliant.
- Honest marketing. Do not advertise async as “no doctor needed” or imply every patient will be prescribed. A licensed provider decides.
Common mistakes with asynchronous telehealth
- Assuming async is legal everywhere. It is not. Map every state.
- Treating approval as automatic. Providers should never feel pressure to approve, and your copy should never promise a prescription.
- Using async for controlled substances. Current federal rules center on in-person or real-time visits.
- Weak intakes. A short form may convert, but it does not give providers enough to evaluate safely.
- No live visit option. Every async program needs a path to video.
How WellieMD helps
WellieMD is a white-label telehealth platform that runs async and live care under your brand. It includes branded intake with branching logic, a licensed provider network, state-aware routing to video visits, secure messaging, e-prescribing with licensed 503A pharmacy routing, payments and subscriptions, refills, labs and wearables in one chart, and HIPAA safeguards with a business associate agreement. All clinical decisions stay with licensed providers. If you are mapping your care model, book a demo and we will build it with you.
Frequently asked questions
What is asynchronous telehealth?
Asynchronous telehealth is care where the patient and provider do not meet in real time. The patient shares intake answers, photos or records, and a licensed provider reviews them later and responds through a secure platform. It is also called store and forward telehealth.
Is async telemedicine legal in every state?
No. Each state sets its own rules for establishing a provider-patient relationship over telehealth, and some do not allow prescribing based only on an online questionnaire. Build a state-by-state matrix and have a healthcare attorney confirm current law.
Can controlled substances be prescribed asynchronously?
Generally, no. At the time of writing, the DEA telemedicine flexibilities run through December 31, 2026 and are built around real-time audio and video visits, not questionnaires. Verify current DEA and state rules before building any controlled substance program.
What is the difference between async vs sync telehealth?
Synchronous telehealth is a live video or audio visit. Asynchronous telehealth happens on each person’s schedule, with the provider reviewing submitted information later. Most digital clinics use both, routing patients to live visits when the law or the provider requires it.
Does a provider still evaluate every async patient?
Yes. A licensed provider reviews each intake, can ask follow-up questions, require a live visit or decline to treat. Async changes the timing of care, not who makes the clinical decision.
This guide is general information, not legal or medical advice. Telehealth and controlled substance rules change often, so confirm current requirements with a healthcare attorney. Prescription products require evaluation by a licensed provider.
Sources
- Telehealth.HHS.gov: Asynchronous direct-to-consumer telehealth
- Telehealth.HHS.gov: Licensing across state lines
- Center for Connected Health Policy: State telehealth policies for online prescribing
- Federal Register: Fourth temporary extension of COVID-19 telemedicine flexibilities for prescription of controlled medications
- U.S. Department of Health and Human Services: HHS and DEA extend telemedicine flexibilities through 2026