## Bottom-line rollout Under the supplied matrix: - **Video antidepressant care can launch in all four states**, but only with the correctly authorized clinician in each state. - **Fully virtual stimulant/ADHD care is lawful only in State Birch**, with the required Birch PMP check before each stimulant prescription. - **Alder and Cedar allow hybrid stimulant care**: a qualifying in-person examination by Clearpath’s own practice first, then video stimulant follow-up/renewals within the 12-month window. An outside primary-care examination does **not** satisfy Alder or Cedar. - **Dune allows no virtual stimulant care** under the current roster because Dr. Lee’s Dune telehealth registration cannot be used for controlled prescribing and Clearpath has no fully Dune-licensed clinician. - Marketing **cannot** say “fully virtual ADHD treatment in all four states.” It may say fully virtual ADHD treatment in **Birch**, and virtual ADHD follow-up in **Alder and Cedar** only for qualifying established patients. --- # 1. Clinician map for video antidepressant care Antidepressants are noncontrolled. Video evaluation is permitted for noncontrolled medication in Alder and Cedar, video evaluation is permitted for both noncontrolled and controlled in Birch, and Dune’s telehealth registration is sufficient for noncontrolled treatment. | State | Clinician who may provide video antidepressant care | Basis | Clinicians who may not | |---|---|---|---| | **Alder** | **Dr. Rowan Lee** | Dr. Lee holds a full Alder license. Alder does not recognize compact privileges or registrations, but Dr. Lee has the required full Alder license. | NP Vale — no Alder authority. | | **Birch** | **Dr. Rowan Lee** | A recognized Birch compact privilege is sufficient. Dr. Lee holds that privilege. | NP Vale — no Birch authority. | | **Cedar** | **NP Amaya Vale** | NP Vale holds a full Cedar license. Clearpath also holds the required Cedar entity permit. | Dr. Lee — not licensed in Cedar. The Cedar entity permit does not give Dr. Lee individual Cedar authority. | | **Dune** | **Dr. Rowan Lee** | An approved Dune telehealth registration is sufficient for noncontrolled treatment. Dr. Lee holds that registration. | NP Vale — no Dune authority. | So the only lawful new-patient video antidepressant rollout is: - **Alder:** Dr. Lee - **Birch:** Dr. Lee - **Cedar:** NP Vale - **Dune:** Dr. Lee The platform must not allow NP Vale to treat patients in Alder, Birch, or Dune, and must not allow Dr. Lee to treat Cedar patients, even though Clearpath holds the Cedar entity permit. --- # 2. Entity-permit requirements Only **State Cedar** expressly requires both: 1. an individual clinician with a full Cedar license, and 2. a Cedar entity permit for the telehealth company. Clearpath holds a Cedar entity permit, and NP Vale holds a full Cedar license. Therefore: - **Cedar entity-permit requirement: satisfied.** - **Alder, Birch, Dune entity permits: not required under the supplied matrix.** Important limitation: the Cedar entity permit is an entity requirement. It does **not** substitute for individual Cedar licensure. Dr. Lee cannot practice in Cedar solely because Clearpath has the permit. --- # 3. New-patient video stimulant prescribing by state Stimulants are controlled medications. New-patient video stimulant evaluation and first prescribing is allowed only where the state matrix permits video controlled evaluation/prescribing and the controlled-substance condition is met. | State | New-patient video stimulant evaluation and first prescribing | Lawful basis / barrier | |---|---|---| | **Alder** | **Blocked** | Dr. Lee has the required full Alder license, but a controlled stimulant may be prescribed only if the **same practice** conducted an in-person examination within the preceding 12 months. A new patient does not have that qualifying same-practice in-person examination. Also, video evaluation is expressly permitted for noncontrolled medication; a new-patient video controlled first evaluation/prescribing is not authorized. | | **Birch** | **Allowed** | Dr. Lee’s recognized compact privilege is sufficient. Birch permits video evaluation for controlled medication. Before the stimulant prescription, Dr. Lee must check the Birch prescription-monitoring database and document the check. | | **Cedar** | **Blocked** | NP Vale has the required full Cedar license and Clearpath has the entity permit, but the **first controlled prescription requires an in-person examination by the prescribing practice**. Video new-patient stimulant prescribing is not authorized. | | **Dune** | **Blocked** | Dr. Lee’s Dune telehealth registration is sufficient only for noncontrolled treatment. A registrant may not prescribe a controlled substance by telehealth under any circumstance. Full Dune licensure is required for controlled prescribing, and Clearpath has no fully Dune-licensed clinician. | Thus, the proposed service “video stimulant evaluation and first prescribing for new patients in all four states” must be blocked in **Alder, Cedar, and Dune**. It may proceed only in **Birch**, with the Birch PMP check. --- # 4. Does an outside primary-care examination satisfy Alder or Cedar? No. | State | Requirement | Outside primary-care exam? | |---|---|---| | **Alder** | The **same practice** must have conducted an in-person examination within the preceding 12 months. | **No.** An unaffiliated outside primary-care clinician is not the same practice. | | **Cedar** | The **prescribing practice** must have conducted the in-person examination for the first controlled prescription. | **No.** An outside primary-care clinician is not the prescribing practice. | This is also consistent with the general rule that an unaffiliated outside clinician’s in-person examination satisfies a state condition only if the matrix expressly says so. The Alder and Cedar matrices do not expressly allow an outside examination. Therefore, Clearpath’s proposed “video stimulant renewals for patients who had an in-person examination with an outside primary-care clinician during the prior year” is **not lawful in Alder or Cedar**. --- # 5. Lawful stimulant-renewal pathways by state ## Alder Alder allows a controlled stimulant prescription only if the **same practice** conducted an in-person examination within the preceding 12 months. Lawful video stimulant renewal pathway: 1. Patient is physically located in Alder. 2. Dr. Lee, the full Alder-licensed clinician, provides the video encounter. 3. The patient has a documented in-person examination by **Clearpath’s Alder practice** within the preceding 12 months. 4. The in-person examination cannot be by an outside primary-care clinician. 5. Location is verified and documented at the start of the video visit. 6. Telehealth consent is documented before the first telehealth service. 7. No Birch-style PMP check is required under the supplied Alder matrix. If the qualifying Alder same-practice in-person examination is missing, is by an outside provider, or is older than 12 months, the video stimulant renewal must be blocked. With the current roster, Dr. Lee is the only listed clinician who can satisfy Alder individual licensure. If Clearpath later hires another full Alder-licensed clinician, that clinician may also satisfy Alder individual licensure, but the in-person examination still must be by Clearpath’s Alder practice. --- ## Birch Birch permits video evaluation for controlled medication. Lawful video stimulant pathway: 1. Patient is physically located in Birch. 2. Dr. Lee provides the visit using the recognized Birch compact privilege. 3. Location is verified and documented at the start. 4. Telehealth consent is documented before the first telehealth service. 5. Dr. Lee completes the adequate video clinical evaluation. 6. Before each stimulant prescription, Dr. Lee checks the Birch prescription-monitoring database. 7. The PMP check is documented. 8. The prescription may then be issued if clinically appropriate. This pathway works for both new patients and renewals. No prior in-person examination is required under the supplied Birch matrix. --- ## Cedar Cedar requires: 1. a full Cedar-licensed clinician, and 2. a Cedar entity permit. Clearpath satisfies the entity-permit requirement, and NP Vale satisfies the individual licensure requirement. Lawful video stimulant renewal pathway: 1. Patient is physically located in Cedar. 2. NP Vale provides the video encounter. 3. Clearpath holds the Cedar entity permit. 4. The patient has a documented in-person examination by **Clearpath’s Cedar prescribing practice**. 5. The video renewal occurs within **12 months after that examination**. 6. Location is verified and documented at the start. 7. Telehealth consent is documented before the first telehealth service. 8. No PMP check is required under the supplied Cedar matrix. An outside primary-care examination does not qualify. If the required in-person examination was not performed by Clearpath’s Cedar practice, or if the 12-month renewal window has expired, the video stimulant renewal must be blocked. --- ## Dune Dune allows no lawful virtual stimulant pathway under the current facts. Reasons: - Dr. Lee has an approved Dune telehealth registration, but a registrant **may not prescribe a controlled substance by telehealth under any circumstance**. - A full Dune license is required for controlled prescribing. - Clearpath has no fully Dune-licensed clinician. - NP Vale has no Dune authority. Therefore, even for renewals, video stimulant prescribing in Dune must be blocked. --- # 6. Required location, consent, and monitoring steps These steps apply to every telehealth encounter unless a state matrix is more specific. ## A. Patient location For every visit: - Verify the patient’s **physical location at the time of service**. - Document the state, date, time, and method of verification. - Apply the law of the state where the patient is physically located, not the state where the clinician is located or the state where Clearpath wants to market the service. - If the patient is located in a state for which the assigned clinician lacks authority, stop or reassign the visit. - If the patient is located in Cedar, also confirm that Clearpath’s Cedar entity permit is active and that the clinician holds a full Cedar license. Examples: - A patient physically located in Alder must be treated under Alder law. - A patient physically located in Birch must be treated under Birch law. - A patient physically located in Cedar must be treated under Cedar law. - A patient physically located in Dune must be treated under Dune law. ## B. Telehealth informed consent Before the first telehealth service: - Obtain telehealth informed consent. - Document it in the patient record. - If the patient had an in-person visit before the first video visit, consent for telehealth is still required before the first video service. ## C. Controlled-substance monitoring Under the supplied matrix, the only express monitoring requirement is in **Birch**: - Before **each** stimulant prescription in Birch, the clinician must check the Birch prescription-monitoring database. - The check must be documented. - This applies to new stimulant prescriptions and renewals. - If the PMP check cannot be completed or documented, the Birch stimulant prescription must be blocked. No PMP requirement is stated for Alder, Cedar, or Dune under the supplied matrix. ## D. Adequate clinical evaluation A prescription requires an adequate clinical evaluation in the modality permitted by the patient’s state. - In **Birch**, video evaluation is permitted for controlled medication. - In **Alder and Cedar**, video evaluation is permitted for noncontrolled medication; controlled prescribing requires the state’s in-person condition. - In **Dune**, video registration authority is only for noncontrolled treatment. --- # 7. Services the platform must block The platform should enforce hard stops for the following. ## Global blocks Block any telehealth service if: 1. Patient physical location has not been verified and documented at the start. 2. Telehealth consent has not been obtained and documented before the first telehealth service. 3. The assigned clinician lacks the required authority for the patient’s state. 4. The service is a Cedar telehealth service and Clearpath’s Cedar entity permit is not active. 5. The service is a controlled-substance service and the applicable controlled-substance condition is not met. ## Clinician-state blocks Block: - Any visit by **Dr. Lee in Cedar**. - Any visit by **NP Vale in Alder, Birch, or Dune**. ## Antidepressant/new-patient noncontrolled services Proposal 1 — video antidepressant evaluation and prescribing for new patients in all four states — may proceed **only** with these assignments: - Alder: Dr. Lee - Birch: Dr. Lee - Cedar: NP Vale - Dune: Dr. Lee Block any other assignment. ## Stimulant new-patient video services Proposal 2 — video stimulant evaluation and first prescribing for new patients in all four states — must be blocked as follows: - **Alder: blocked** for new-patient video stimulant first prescribing. - **Birch: allowed**, with Birch PMP check and documentation before the prescription. - **Cedar: blocked** for new-patient video stimulant first prescribing. - **Dune: blocked** entirely for video stimulant prescribing. ## Stimulant renewals based only on outside primary-care examination Proposal 3 — video stimulant renewals for patients who had an in-person examination with an outside primary-care clinician during the prior year — must be blocked as follows: - **Alder: blocked** if the only qualifying examination is by an outside primary-care clinician. - **Birch: outside examination not required**; renewal may proceed if all Birch requirements are met, including the PMP check. - **Cedar: blocked** if the only qualifying examination is by an outside primary-care clinician. - **Dune: blocked** regardless, because no controlled telehealth prescribing is allowed under the current roster. ## Birch stimulant block Block any Birch stimulant prescription unless: - Dr. Lee is the treating clinician; - the patient is physically located in Birch; - location and consent requirements are met; - the Birch PMP check is completed before the prescription; and - the PMP check is documented. ## Dune controlled-substance block Block **all** Dune telehealth stimulant prescribing by any Clearpath clinician under the current roster. --- # 8. Accurate state-by-state rollout map | State | Video antidepressant care | New-patient video stimulant care | Lawful video stimulant pathway | Marketing position | |---|---|---|---|---| | **Alder** | **Yes.** Dr. Lee may provide video antidepressant evaluation and prescribing. | **No.** New-patient video stimulant first prescribing is not lawful. | **Hybrid only.** Video stimulant renewals are lawful only if Clearpath’s Alder practice documented an in-person examination of the patient within the preceding 12 months. Outside primary-care exams do not qualify. | Do not advertise fully virtual ADHD in Alder. Advertise video depression care and virtual ADHD follow-up for qualifying established patients. | | **Birch** | **Yes.** Dr. Lee may provide video antidepressant care. | **Yes.** Dr. Lee may perform new-patient video stimulant evaluation and first prescribing. | **Fully virtual.** Video stimulant new and renewal prescribing is lawful if Dr. Lee checks and documents the Birch PMP before each stimulant prescription. | May advertise fully virtual ADHD treatment in Birch. | | **Cedar** | **Yes.** NP Vale may provide video antidepressant care because Clearpath holds the Cedar entity permit. | **No.** New-patient video stimulant first prescribing is not lawful. | **Hybrid only.** First controlled prescription requires in-person examination by Clearpath’s Cedar prescribing practice. Later video renewals are lawful for 12 months after that examination. Outside primary-care exams do not qualify. | Do not advertise fully virtual ADHD in Cedar. Advertise video depression care and virtual ADHD follow-up for qualifying established patients. | | **Dune** | **Yes.** Dr. Lee may provide video antidepressant care using the approved Dune telehealth registration. | **No.** Dr. Lee may not prescribe a controlled substance by telehealth, and Clearpath has no fully Dune-licensed clinician. | **No virtual stimulant pathway** under current facts. | Do not advertise virtual ADHD or virtual stimulant treatment in Dune. | --- # 9. Marketing claim Clearpath **may not** advertise: > “Fully virtual ADHD treatment in all four states.” That claim is inaccurate because: - Alder requires a same-practice in-person examination before controlled stimulant prescribing. - Cedar requires an in-person examination by the prescribing practice for the first controlled prescription. - Dune permits no virtual controlled-substance prescribing under the current roster. An accurate marketing statement would be: > “Clearpath provides video behavioral health visits for depression in Alder, Birch, Cedar, and Dune. We offer fully virtual ADHD stimulant care in Birch. In Alder and Cedar, we provide virtual ADHD follow-up for established patients who have had a qualifying in-person evaluation at Clearpath’s own clinic in that state within the required 12-month period. We do not provide virtual stimulant treatment in Dune.” Another acceptable version: > “Fully virtual ADHD treatment in State Birch; hybrid virtual follow-up for ADHD in States Alder and Cedar; no virtual ADHD stimulant treatment in State Dune.”