Practice agreement

In the United States, a practice agreement is a written document between a physician and one or more other licensed health professionals that sets out the medical duties the professionals can perform, the conditions attached to that work, and the oversight the physician provides. State law gives the instrument many different names. Among them are collaborative practice agreement, supervision agreement, delegation agreement, standard care arrangement, prescriptive authority agreement and written protocol. The name a jurisdiction chooses usually signals the legal theory on which the professional's authority rests.

Practice agreements are creatures of state law. A state's medical practice act, together with the acts governing nursing, physician assistants and pharmacy, determines whether an agreement is required, who signs it, what it must contain, whether it is filed with or approved by a licensing board, and how many clinicians one physician may cover. Nurse practitioners and other advanced practice registered nurses, physician assistants, pharmacists and, for specific delegated tasks, registered nurses practice under them. There is no federal practice agreement; federal payment programs such as Medicare generally defer to state scope-of-practice law in determining whether a service was lawfully furnished.

The requirement has been a central subject of the scope of practice debate in American health policy. Between 2010 and 2026 a majority of states removed or reduced the agreement requirement for nurse practitioners while extending agreement-based authority to pharmacists. As a result, the number of professions practicing under such an instrument grew even as the number of states requiring one for any given profession fell.

Terminology

No single term is used nationally. A 2026 survey of the 50 states, the District of Columbia and Puerto Rico identified 57 distinct statutory or regulatory names for the instrument across the three principal professions. The names fall into four broad families. The family a state's term belongs to is generally a better guide to the substance of the requirement than the term itself:

• Collaboration. Terms built on collaborative, collaboration or arrangement: collaborative practice agreement, written collaborative agreement, collaborative practice arrangement, Ohio's standard care arrangement, Colorado's articulated plan, Vermont's formal collaborative provider agreement. These describe a relationship between two independently licensed professionals rather than a transfer of the physician's authority.
• Supervision. Supervisory practice agreement, written supervision agreement, supervision agreement. These place the second professional's work under the physician's license and, in most states, make the physician answerable for it.
• Delegation. Delegation agreement, written protocol, Utah's delegation of services agreement, Georgia's job description for physician assistants. These rest on the doctrine that a physician may delegate acts that are otherwise the practice of medicine, and the written instrument records what has been delegated.
• Prescriptive authority. Texas's prescriptive authority agreement and Kentucky's collaborative agreement for prescriptive authority cover only the writing of prescriptions, leaving the rest of the professional's scope to the general practice act.

Several states use a term from one family for a mechanism that belongs to another. Florida calls the nurse practitioner instrument a written protocol, although the underlying relationship is supervisory, and Mississippi recognizes a "board-approved protocol or standing order" for nurse practitioners. Terms are also reused across professions with different meanings: written protocol names the pharmacist instrument in Texas, Alaska, Mississippi and New Jersey, and the nurse practitioner and physician assistant instrument in Florida.

A related but distinct instrument, the medical director agreement, names a physician as the clinical authority for a facility or business, such as a medical spa, an urgent care clinic, an opioid treatment program or a home-care company, rather than for an individual clinician. All 52 jurisdictions surveyed recognize some form of it, and a practice may need both.

Legal basis

Practice agreements arise from three separate bodies of state law that do not always align.

The medical practice act defines the practice of medicine and the circumstances in which a physician may delegate parts of it. Delegation-family instruments derive directly from this authority; Michigan, for example, permits a licensee to delegate acts to a person otherwise unlicensed to perform them, subject to supervision.

The professional practice act for the second profession sets the conditions on that profession's own license. New York requires a nurse practitioner to have a written practice agreement with a collaborating physician for the first 3,600 hours of practice, and Virginia provides for a practice agreement covering both nurse practitioners and physician assistants.

Board rules supply most of the operative detail. The required contents of an agreement, the frequency of chart review, the retention period and any filing obligation are usually found in regulations of the board of medicine, board of nursing or board of pharmacy rather than in statute. North Carolina's requirements for nurse practitioners appear in the joint rules of its medical and nursing boards, and Massachusetts sets its collaborative drug therapy management requirements by regulation.

These three bodies of law can disagree, as when a nursing board rule permits what a medical board rule restricts, or the reverse. Practices in the affected state generally follow the more restrictive requirement, because either board may discipline its own licensee.

Contents

Required contents vary by state, but the elements recur across jurisdictions:

• the names, license numbers and addresses of the parties;
• the practice locations and settings the agreement covers;
• the categories of drugs the second professional may or may not prescribe, and any restriction on controlled substances;
• a plan for consultation and referral, including coverage when the physician is absent and, in some states, a named alternate physician;
• the method and frequency of chart review or quality assurance, and any requirement for periodic meetings;
• the term of the agreement, and a requirement that it be reviewed and signed annually;
• retention of the signed agreement at the practice site and, in some states, filing with a licensing board.

Texas requires a prescriptive authority agreement to state the parties' names, addresses and license numbers; the nature of each party's practice and its locations; the categories of drugs covered; and a plan for consultation, referral and emergency coverage. The agreement must be reviewed annually.

Filing practice differs sharply. Some states require the agreement only to be held at the practice site and produced on request; others require registration with a board before the professional may practice. Most states do not require the physician to be present on site, and agreements are commonly held with a physician at a different location. Critics and defenders of that arrangement, sometimes called remote collaboration, characterize it very differently.

By profession

Variation among the states

The table lists the principal instrument each jurisdiction names for the three professions most often covered. A dash indicates that the jurisdiction does not name a specific instrument for that profession; where a jurisdiction names more than one, both appear. Names are those used in the governing statute or board rule as of September 2026.

Ratios and other limits

Many states cap the number of clinicians one physician may cover. Texas limits a delegating physician to seven full-time-equivalent advanced practice registered nurses and physician assistants combined, with exceptions for medically underserved areas and facility-based practice. Other states set the limit by headcount rather than full-time equivalents, count nurse practitioners and physician assistants separately, or set no numeric limit at all.

Further conditions commonly attached to an agreement include a geographic limit on the distance between the physician and the practice site; a requirement that the physician practice in a related specialty; a minimum frequency of on-site visits; a percentage of charts subject to review; and a minimum number of hours of experience before the professional may hold an agreement or practice without one.

Because the physician's participation is a condition of the second professional's licensure, the agreement usually carries a fee. A market has developed in which physicians contract to serve as the collaborating, supervising or delegating physician for practices in which they do not otherwise work. Critics describe these arrangements as a payment for a signature that produces no clinical oversight; defenders describe them as the mechanism that allows clinics in areas without a resident physician to operate at all.

Policy debate

The requirement is contested, and the arguments are largely economic and evidentiary rather than technical.

The Federal Trade Commission has argued that mandatory physician-supervision requirements can raise costs and restrict competition without a corresponding safety benefit, and has urged states to scrutinize them. The Institute of Medicine reached a similar conclusion on access grounds, and nursing organizations argue that the requirement bears no relation to the individual professional's competence and is a barrier to practice in rural and underserved areas.

The American Medical Association and other physician organizations oppose removing the requirement, arguing that differences in the length and content of training justify physician-led teams and that patients may not distinguish between clinician types.

A separate line of criticism accepts the requirement in principle but questions its administration: agreements that are signed and filed but never acted on, chart-review obligations that are not met, and physicians who cover the statutory maximum number of clinicians across several states. This critique is made by participants on both sides of the scope-of-practice question, since an unenforced requirement supplies neither the oversight its defenders claim nor the access its opponents seek.

See also

• Collaborative practice agreement
• Scope of practice
• Mid-level practitioner
• Nurse practitioner
• Physician assistant
• Registered Nurse

References

External links

• State Practice Environment - American Association of Nurse Practitioners
• APRN regulation - National Council of State Boards of Nursing
• Practice agreement glossary by state and statutory name - Practice Agreement