Can I legally prescribe a refill of metoprolol succinate (metoprolol) 25 mg for a hypertensive patient who has not had an in‑person or telehealth encounter in nine months and has relocated to a new location?

Can You Legally Prescribe Metoprolol to a Patient Not Seen in 9 Months?

No, you should not prescribe metoprolol succinate to this patient without establishing a current provider-patient relationship through a clinical encounter, even though she was previously established at your practice. While telemedicine guidelines permit prescribing controlled and non-controlled medications via live interactive video visits, they consistently require an active clinical relationship with appropriate evaluation before prescribing 1.

Legal and Regulatory Framework

Telemedicine Prescribing Standards

• Live interactive telemedicine visits are acceptable for prescribing antihypertensive medications, including metoprolol, as a suitable alternative to in-person encounters for established patients 1.
• The American Academy of Sleep Medicine position paper states that providers must have an active current license in the state where the substance is being prescribed (the originating site where the patient is located) 1.
• Consistent and clear electronic documentation of the evaluation and management plan is required before prescribing 1.

Store-and-Forward vs. Live Interactive Care

• Store-and-forward telemedicine (reviewing records and providing recommendations without direct patient interaction) is not appropriate for direct prescribing decisions—it is designed for consultations to referring providers, not for writing prescriptions directly to patients 1.
• E-messaging or asynchronous communication alone does not meet the standard for establishing the clinical relationship needed to prescribe medications 1.

Clinical Approach to This Situation

Immediate Action Required

• Schedule a telehealth visit (live video) within 24-48 hours to re-establish care and assess her current hypertension status 1.
• During this visit, obtain current blood pressure readings (ideally from home monitoring if she has a device), review symptoms, assess medication adherence history, and evaluate for any new contraindications 1.
• Verify her current address and confirm you hold an active license in the state where she now resides 1.

What to Assess During the Telehealth Visit

• Confirm her blood pressure elevation that led to dental office refusal—ask for specific readings and timing 1.
• Evaluate for hypertension-mediated organ damage symptoms: chest pain, shortness of breath, headaches, visual changes, or neurological symptoms 1.
• Review why the other provider discontinued metoprolol and what alternative treatment (if any) was attempted 1.
• Assess for any new medical conditions, medications, or contraindications to beta-blockers that have developed in the past 9 months 1.

Prescribing Decision After Telehealth Visit

• If blood pressure is severely elevated (≥160/100 mmHg) and she has no contraindications, restart metoprolol succinate 25 mg once daily immediately 1.
• Metoprolol succinate 25 mg provides 24-hour beta-blockade with once-daily dosing and is appropriate for mild-to-moderate hypertension 2, 3.
• Provide a 30-day supply initially with mandatory follow-up in 2-4 weeks (via telehealth or in-person at one of your other facilities) to assess response and titrate if needed 1.

Documentation Requirements

• Document the telehealth encounter thoroughly, including blood pressure readings, clinical assessment, rationale for restarting metoprolol, and follow-up plan 1.
• Note that this represents re-establishment of care after a 9-month gap, not continuation of an active treatment relationship 1.

Alternative If Telehealth Is Not Feasible

• If you cannot conduct a live interactive telehealth visit and she cannot come to one of your facilities, provide her with resources to establish care locally rather than prescribing without an encounter 1.
• Consider providing a brief written summary of her previous treatment (metoprolol succinate 25 mg was effective) that she can share with a new local provider to facilitate continuity 1.

Critical Pitfalls to Avoid

• Do not prescribe based solely on a phone call or e-message—this does not meet the standard for establishing a clinical relationship required for prescribing 1.
• Do not assume her clinical status is unchanged after 9 months without evaluation—new contraindications (e.g., heart block, severe bradycardia, decompensated heart failure) may have developed 1.
• Do not provide a 90-day supply without recent clinical assessment—monthly visits are recommended until blood pressure is controlled 1.
• Verify state licensure before prescribing via telemedicine to a patient who has relocated, as prescribing across state lines without proper licensure is illegal 1.