TITLE 22. EXAMINING BOARDS

PART 11. TEXAS BOARD OF NURSING

CHAPTER 217. LICENSURE, PEER ASSISTANCE AND PRACTICE

Introduction. The Texas Board of Nursing (Board) adopts amendments to 22 Texas Administrative Code §217.24, relating to Telehealth Services and Telemedicine Medical Services in Nursing, formerly Telemedicine Medical Service Prescriptions, with changes to the proposed text published in the December 19, 2025 issue of the Texas Register (50 TexReg 8155). The rule will be republished.

Reasoned Justification. The adopted amendments to Board Rule 217.24 reflect changes required by House Bill 1700 (89th Legislature), which amended Texas Occupations Code §111.004. Specifically, the bill specifies the informed consent documentation that is required when licensees perform telehealth services or telemedicine medical services. The adopted amendments ensure that a written record of informed consent is maintained when nursing services are provided via telehealth. The Board carefully considered public comments regarding the proposed amendments, including concerns about potential administrative burdens and impacts on patient access to care. In response, the Board made revisions to clarify the rule language and ensure that the requirements are consistent with legislative intent and existing standards of care. The rule, as adopted, maintains standardized documentation and retention requirements for informed consent while avoiding unnecessary or duplicative provisions.

Section by Section Overview.

The adopted amendments to §217.24 implement recent statutory changes requiring agencies regulating health professionals who provide telemedicine medical services and telehealth services to adopt rules standardizing the format and retention of patient consent records. These amendments implement Texas Occupations Code §111.004, as amended effective September 1, 2025.

Subsection (a) incorporates the statutory definitions of "telehealth service" and "telemedicine medical service" from Texas Occupations Code §111.001 to ensure consistency with governing law.

Subsection (b) clarifies that the rule's standards apply equally to video and audio-only encounters, implementing the statutory requirement that consent documentation provisions address audio-only formats based on the appropriate standard of care.

Subsection (c) standardizes informed consent documentation for telehealth and telemedicine services, allowing written or verbal consent and requiring documentation of verbal consent, including the date given and identification of any responsible party providing consent.

Subsection (d) provides uniform record retention requirements for consent documentation, consistent with existing Texas law, including specific provisions for minors, thereby implementing the statutory mandate to standardize retention of consent records.

Subsections (e) through (i) update existing prescription-related provisions, including updated cross-references.

Public Comment. The Board received five comments on the proposal. The commentors include Dr. Jennie Berkovich, DO, FAAP, VP of Physical Health at Hazel Health; Dr. Tracy Hicks, DNP, MBA, APRN, President, Texas Nurse Practitioners; Mr. Hunter Young, Head of State Government Relations, ATA Action; Access TeleCare; and Ms. Nora Cox, CEO, Texas e-Health Alliance. All five commentors primarily focused on similar concerns and objections to the rule as proposed and their concerns are addressed together in the Board's response.

Comment Summaries:

Dr. Jennie Berkovich, DO, FAAP, VP of Physical Health at Hazel Health, supports the Board's goals of transparency, patient protection, and consistent telehealth standards. However, she objects to the visit-specific disclosure of the treating APRN's identity, license information, practice location and delegating physician details in writing at each patient encounter. She explains that in a school-based telehealth platform, parental consent is typically obtained in advance of care to ensure timely access to students. She emphasizes that current consent processes already include the nature of telehealth services, provider information, provider licensure, supervision structures, and contact information for parental questions or concerns. Requiring new written consent for each visit would delay care. She also notes that requiring remote providers to disclose their primary practice address and phone number may suggest that the Board is requiring remote providers to disclose their private addresses and personal phone numbers in addition to the business or organizational contact information already provided. Dr. Berkovich suggests modifying the proposed rule to allow information regarding nurse's identity or delegation authority to be provided through visual or verbal disclosure at commencement of telehealth encounter, rather than through a written consent form. She further suggests that the Board clarify that the appropriate practice address and phone number can include the corporate address and business phone number.

Dr. Tracy Hicks, DNP, MBA, APRN, as President and on behalf of Texas Nurse Practitioners, submitted comments strongly opposing proposed §217.24, citing key provisions TNP believes conflict with HB 1700 and create unnecessary administrative burdens. TNP strongly opposes the requirement that APRNs disclose their delegating physician's name, license number, and contact information as part of telemedicine informed consent. TNP argues this requirement is duplicative because physician information is already disclosed through other legal mechanisms (e.g., prescriptions), lacks statutory authority under the Nursing Practice Act and HB 1700, and unfairly singles out telemedicine encounters. The organization asserts this provision would confuse patients, burden providers, and undermine the professional accountability of APRNs.

Additionally, TNP opposes requiring telehealth informed consent to be obtained through a signed, written document. They argue this directly conflicts with HB 1700, which explicitly requires licensing boards to allow consent documentation in audio-only formats. TNP urges the Board to adopt language which allows informed consent to be obtained in writing or verbally with appropriate documentation in the medical record. TNP requests removal of the delegating physician disclosure provision and revision of the consent requirements to explicitly allow verbal consent prior to any adoption. TNP urges the Board to consider consultation with its APRN Advisory Committee to ensure alignment with statutory authority, nursing regulation, and patient access to telehealth services.

Access TeleCare, a Dallas-based company that is the nation's largest provider of acute specialty telemedicine, submitted comments expressing concerns about additional administrative requirements that could hinder telemedicine access without improving patient safety. Access relies heavily on APRNs to deliver specialty telemedicine services. Access opposes the requirement for written informed consent that includes detailed supervising or delegating physician information. Supervising physician relationships are already thoroughly documented through hospital credentialing, medical staff privileges, and Texas Medical Board delegation systems. Requiring the same information in telemedicine consent forms would be duplicative and increase administrative burdens for clinicians and hospital staff. Access would request a hospital-based exemption should the requirement remain.

Mr. Hunter Young, Head of State Government Relations, submitted comments for ATA Action, identified as the American Telemedicine Association's affiliated trade association focused on advocacy. While supporting the Board's implementation of House Bill 1700, ATA Action opposes certain provisions arguing that they exceed statutory authority and could unnecessarily restrict telehealth access for Texas patients. ATA Action contends that requiring a signed, written informed consent goes beyond HB 1700 and Texas Occupations Code §111.004, which require documentation of informed consent but do not mandate signatures. The requirement could be impractical for digital and audio-only telehealth encounters, create compliance ambiguity, and impose higher standards on telehealth than on in-person care, contrary to modality-neutral policy principles.

Additionally, ATA Action opposes the requirement that APRNs disclose detailed information about delegating physicians (name, license number, practice address, and phone number) during the informed consent process. The organization argues this is not contemplated by HB 1700 and is already governed under existing Texas law. ATA Action notes that other Texas licensing boards implementing HB 1700 have not adopted similar signature or physician disclosure requirements and urges alignment to reflect legislative intent and ensure consistency.

Ms. Nora Cox, CEO of Texas e-Health Alliance (TeHA) submitted comments strongly opposing the proposed amendments to 22 TAC §217.24, arguing that they conflict with the plain language and intent of HB 1700 and would impose unnecessary administrative burdens on nurses providing telehealth and telemedicine services.

TeHA explains that HB 1700 was designed to ensure clear guidance on how informed consent may be documented for virtual encounters, including audio-only services, without imposing a single rigid standard across professions. The proposed rule's requirement that informed consent be obtained through a signed, written document, with no allowance for electronic signatures or audio-only consent, directly contradicts HB 1700's explicit requirement to allow consent documentation in an audio-only format.

TeHA also opposes the proposed requirement that APRNs disclose the delegating physician's name, Texas medical license number, and contact information as part of the informed consent process. They argue this information is already disclosed through other legal mechanisms (such as prescriptions), making the requirement duplicative, administratively burdensome, and potentially confusing for patients. TeHA notes that current law does not impose this disclosure requirement in telemedicine or in-person care, and that it exceeds both the scope and intent of HB 1700.

TeHA urges the Board to revise the rule to align with HB 1700 and follow models adopted by other Texas licensing boards, such as the Texas Board of Physical Therapy Examiners, which expressly allow both written and verbal consent with appropriate documentation in the medical record. TeHA recommends deleting subsection (c)(2) entirely and adopting a more flexible, modality-neutral framework.

Agency Response:

The Board has reviewed and carefully considered the comments provided by Dr. Berkovich, Texas Nurse Practitioners (TNP), Access TeleCare, ATA Action, and the Texas e-Health Alliance (TeHA). The Board agrees with the concerns raised regarding the proposed administrative requirements and the potential for these provisions to create barriers to patient access.

In response to this feedback, the Board has removed the offending sections which parties identified as duplicative or overly burdensome. Specifically, the Board has eliminated the requirement for a signed, written informed consent at each encounter and the mandate for Advanced Practice Registered Nurses (APRNs) to disclose detailed delegating physician information as part of the telehealth consent process. Further, the Board has also removed all of the first subsection (d) relating to a prescribed format for "special" informed consent for delivery models, treatment methods, and limitations associated with a telehealth service encounter. The Board agrees that it would be improper to adopt a prescribed format, which may be viewed as unnecessarily duplicative of current informed consent requirements, or impose additional requirements for telehealth services that are inconsistent with the same procedures in an in-person setting.

Furthermore, the Board has updated the amendments to include language consistent with similar standards adopted by other occupational agencies. These revisions ensure that informed consent may be obtained in a variety of formats, including verbal or audio-only, provided it is appropriately documented in the medical record. This approach aligns the rule with the legislative intent of HB 1700, maintains modality-neutral policy principles, and ensures a consistent regulatory framework across Texas licensing boards. Minor edits to correct grammar and punctuation were included.

Statutory Authority. This amendments are adopted under the authority of Texas Occupations Code §301.151 and Texas Occupations Code §111.004. Section 301.151 grants the Board general rulemaking authority to adopt and enforce rules necessary to perform its duties, regulate the practice of professional and vocational nursing, establish standards of professional conduct, and conduct proceedings under Chapter 301. Section 111.004, as amended by the Legislature effective September 1, 2025, requires each agency with regulatory authority over a health professional who provides telemedicine medical services or telehealth services to adopt rules standardizing the format and retention of records related to a patient's consent to treatment, data collection, and data sharing, including provisions addressing consent documentation in audio-only formats based on the appropriate standard of care. The amendments to §217.24 are adopted to implement and comply with these statutory requirements.

Cross reference to statute. The adopted amendments affect Texas Occupations Code §111.004.

§217.24. Telehealth Services and Telemedicine Medical Services in Nursing.

(a) Definitions.

(1) "Telehealth service" shall have the meaning defined by Texas Occupations Code §111.001(3).

(2) "Telemedicine medical service" shall have the meaning defined by Texas Occupations Code §111.001(4).

(b) The same standards discussed in this rule are applicable to telehealth services and telemedicine medical services regardless of whether the patient interaction occurs in a video format or an audio-only format.

(c) A nurse must document informed consent for either telehealth services or telemedicine medical services in the medical record. Consent is acceptable either in written format or verbally. If the informed consent is obtained verbally, it must be documented in the patient's medical record and must include the date that the verbal consent is given. If the informed consent is provided by a responsible party of the patient, the name and relationship to the patient must be included.

(d) Informed consent records must be retained at least seven years from the date of last treatment by a nurse or longer if required by other federal or state law. If a patient is under 18 years old, informed consent records must be retained until the patient reaches 21 years old or seven years from the date of last treatment, whichever is longer.

(e) Issuance of Prescriptions. The validity of a prescription issued as a result of a telemedicine medical service is determined by the same standards that would apply to the issuance of the prescription in an in-person setting.

(f) This rule does not limit the professional judgment, discretion, or decision-making authority of a licensed practitioner. A licensed practitioner is expected to meet the standard of care and demonstrate professional practice standards and judgment, consistent with all applicable statutes and rules when issuing, dispensing, delivering, or administering a prescription medication as a result of a telemedicine medical service.

(g) A valid prescription must:

(1) be issued for a legitimate medical purpose by a practitioner as part of a patient-practitioner relationship as set out in §111.005, Texas Occupations Code; and

(2) meet all other applicable laws before prescribing, dispensing, delivering, or administering a dangerous drug or controlled substance.

(h) Any prescription drug orders issued as the result of a telemedicine medical service are subject to all regulations, limitations, and prohibitions set out in the federal and Texas Controlled Substances Act, Texas Dangerous Drug Act, and any other applicable federal and state law.

(i) Limitation on Treatment of Chronic Pain. Chronic pain is a legitimate medical condition that needs to be treated, but must be balanced with concerns over patient safety and the public health crisis involving overdose deaths. The Legislature has already put into place laws regarding the treatment of pain and requirements for registration and inspection of pain management clinics. Therefore, the Board has determined clear legislative intent exists for the limitation of chronic pain treatment through a telemedicine medical service.

(1) For purposes of this rule, chronic pain has the same definition as used in 22 Texas Administrative Code §172.1(2).

(A) Telemedicine medical services used for the treatment of chronic pain with scheduled drugs by any means other than via audio and video two-way communication is prohibited, unless a patient:

(i) is an established patient of the APRN being treated for chronic pain;

(ii) is receiving a prescription that is identical to a prescription issued at the previous visit; and

(iii) has been seen by the prescribing APRN, physician, or other health professional as defined in Tex. Occ. Code §111.001(1) in the last 90 days, either:

(I) in-person; or

(II) via telemedicine medical service using audio and video two-way communication.

(B) An APRN, when determining whether to utilize telemedicine medical services for the treatment of chronic pain with controlled substances as permitted by paragraph (1)(A) of this subsection, shall give due consideration to factors that include, at a minimum, the date of the patient's last in-person visit, patient co-morbidities, and occupational related COVID risks. These are not the sole, exclusive, or exhaustive factors an APRN should consider under this rule.

(C) If a patient is treated for chronic pain with scheduled drugs through the use of telemedicine medical services as permitted by paragraph (1)(A) of this subsection, the medical records must document the exception and the reason that a telemedicine medical service visit was conducted instead of an in-person visit.

(2) For purposes of this rule, acute pain has the same definition as used in 22 Texas Administrative Code §172.1(1). Telemedicine medical services may be used for the treatment of acute pain with scheduled drugs, unless otherwise prohibited under federal and state law.

The agency certifies that legal counsel has reviewed the adoption and found it to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on March 20, 2026.

TRD-202601341

James W. Johnston

General Counsel

Texas Board of Nursing

Effective date: April 9, 2026

Proposal publication date: December 19, 2025

For further information, please call: (512) 305-6879