As a physician with prescriptive authority in Texas, entering into delegation agreements with advanced practice providers—such as physician assistants (PAs) and advanced practice registered nurses (APRNs)—can enhance your practice’s efficiency and patient care capabilities. However, these arrangements come with a complex web of legal obligations under Texas law. Noncompliance can jeopardize your medical license, expose you to disciplinary action by the Texas Medical Board, and even result in civil or criminal liability. To help you navigate this landscape, here are five critical steps you should be taking to remain compliant with Texas laws and regulations governing prescriptive authority and delegation agreements. We will break this down with practical advice, rooted in the relevant statutes and rules, to keep your practice on solid legal footing.

1. Ensure a Valid and Comprehensive Prescriptive Authority Agreement (PAA)

The cornerstone of delegating prescriptive authority in Texas is the prescriptive authority agreement (PAA), a written document that formalizes the relationship between you and your advanced practice providers. Under Texas Occupations Code §157.0511, a PAA is mandatory for any physician delegating the act of prescribing or ordering a drug or device to a PA or APRN. This is not optional—it is a legal prerequisite.

Your PAA must meet specific requirements outlined in §157.0512(e). It needs to be in writing, signed and dated by you and the advanced practice provider, and include key details such as:

• The names, addresses, and professional license numbers of all parties
• The nature of your practice, practice locations, or settings
• The types or categories of drugs or devices the advanced practice provider may (or may not) prescribe
• A general plan for consultation and referral, a process for handling patient emergencies, and a communication framework between you and the advanced practice provider
• If you are using alternate physician supervision, the designation of one or more alternate physicians

Additionally, Texas law requires that you review, sign, and date the PAA (and any amendments) at least annually. This is not just a formality—failure to keep the agreement current could be construed as inadequate supervision, a violation of Texas Occupations Code §164.053(a)(8). Imagine a Texas Medical Board investigation where an outdated PAA becomes exhibit A against you. To avoid this, set a calendar reminder for your annual review and treat it as a non-negotiable part of your compliance routine.

2. Register Your Delegation Properly and Timely with the Texas Medical Board

Texas law mandates that you register your delegation of prescriptive authority with the Texas Medical Board. Senate Bill 532 (2009) established this requirement, and it is codified in 22 Texas Administrative Code §169. You must use the Texas Medical Board’s Online Supervision and Prescriptive Delegation Registration System to register each PA or APRN to whom you delegate prescriptive authority. Hard-copy forms are no longer accepted unless you are ineligible for online registration (e.g., you lack a Texas practice address).

Eligibility hinges on having a full, active, and unrestricted license—temporary licenses, telemedicine licenses, or licenses under a board order cannot register. Registration must include:

• The advanced practice provider’s name and license number
• The PAA execution date 
• The practice address where prescribing will occur

Critically, any changes—such as adding or terminating an advanced practice provider—must be updated within 30 days. If you miss that window, you could face liability in a Texas Medical Board investigation, as the board explicitly warns that late updates do not retroactively absolve you.

Why does this matter? The Texas Medical Board shares this data with the Texas Board of Nursing and Texas Physician Assistant Board under Texas Occupations Code §157.0513. If an advanced practice provider under your supervision gets investigated, an unregistered delegation could amplify your exposure. Our advice: treat registration like a patient chart—document it accurately and promptly. A quick login to the Texas Medical Board system after signing a PAA can save you headaches later.

3. Provide Adequate Supervision and Conduct Required Meetings

Delegation does not mean abdication. The Texas Medical Practice Act (Texas Occupations Code Chapter 157) requires “adequate supervision” of your advanced practice providers, and the specifics of what that entails are fleshed out in your PAA and Texas Medical Board rules. Under §157.0512(f), for PAAs executed prior to September 1, 2019, you must meet face-to-face with your PA or APRN at least monthly, unless certain exceptions apply (e.g., if they have practiced under supervision for five of the last seven years, reducing the requirement to one year of monthly meetings). After that initial period, quarterly in-person meetings suffice, supplemented by monthly remote meetings via videoconferencing. For PAAs executed after September 1, 2019, monthly face-to-face meetings are no longer required. Instead, meetings with your advanced practice provider must occur periodically and in a manner determined by the parties, which could include virtual meetings.

These meetings are not casual check-ins—they are a legal obligation to discuss patient treatment, care plans, and improvements. In addition to these meetings, you also need a quality assurance plan, including chart reviews, with the number of charts determined by you and the advanced practice provider based on factors like their experience and patient complexity (§157.0512(e)(9)). There is no magic number, but skimping here could signal inadequate supervision to the Texas Medical Board. While not binding in Texas, other state medical boards have set minimum chart review at 5-10%, with a majority at the 10% level.

Remember, if you are not meeting regularly or reviewing sufficient charts, and there is a bad outcome involving the advanced practice provider, the Texas Medical Board could argue you should have known about a problem. Protect yourself by scheduling these meetings like patient appointments—non-negotiable and documented. Keep a log of dates, attendees, and topics discussed. If you are using an alternate physician, ensure they are looped in as required by the PAA.

4. Understand and Respect Limits on Delegation Numbers and Scope

Texas law caps the number of advanced practice providers to whom you can delegate prescriptive authority, with exceptions for certain settings. Under Texas Occupations Code §157.0512, you may delegate to a maximum of seven PAs or APRNs (or their full-time equivalents), unless you are in a facility-based practice (e.g., a hospital) or serving a medically underserved population (§157.0512(d)). There is no limit on how many physicians can supervise a single advanced practice provider, but your personal cap is firm outside those exceptions.

Scope matters too; PAs and APRNs can prescribe controlled substances (Schedules III-V, with Schedule II allowed in limited hospital-based scenarios), but they need their own DEA numbers, and your name must be on file with the DEA as the delegating physician (22 Texas Administrative Code §193.6). Dangerous drugs—non-controlled prescription medications—are fair game, but your PAA must explicitly define what they can and cannot prescribe.

Violating these limits or scopes is a fast track to Texas Medical Board scrutiny. For example, delegating to eight advanced practice providers in a private practice without an exception could trigger a complaint under Texas Occupations Code §164.051(a)(6) for unprofessional conduct. To stay compliant, audit your delegation roster regularly. If you are nearing the cap or expanding your practice, consult the Texas Medical Board’s facility-based or underserved population criteria to see if you qualify for an exception.

5. Disclose Disciplinary History and Respond to Investigations Promptly

Transparency with your advanced practice provider is required. Before signing a PAA, you must disclose any prior discipline by the Texas Medical Board or other licensing boards to your advanced practice provider (§157.0512(b-1)). Once the PAA is in place, if you are notified of an investigation—especially one tied to delegation—you must inform the advanced practice provider immediately. The Texas Medial Board, Texas Board of Nursing, and Texas Physician Assistant Board share investigation data under §157.0513, so trying to hide a problem will not work.

If the Texas Medical Board requests your PAA or audits your practice, you have three business days to comply (§157.0512(m)). The Texas Medical Board can inspect your site with reasonable notice unless it would jeopardize an investigation (§157.0514). Noncompliance could escalate to disciplinary action under Texas Occupations Code §164.053 for failing to cooperate with the board.

Practical takeaways:

Keep your PAA and supervision records organized and accessible. If a complaint lands on your desk, do not delay—notify your advanced practice providers and consider consulting with a healthcare attorney. A swift, compliant response may mitigate exposure. Proactive compliance is your best defense.

Delegating prescriptive authority to advanced practice providers can transform your practice, but it is a privilege that demands diligence. Texas laws create a framework that balances flexibility with oversight. By maintaining a robust PAA, registering delegations promptly, supervising actively, respecting limits, and staying transparent, you are not just checking boxes—you are safeguarding your license and reputation.

As a healthcare attorney, I have seen physicians stumble into Texas Medical Board complaints over sloppy delegation practices. Do not make the same mistake. Build these habits into your workflow, lean on the Texas Medical Board’s online tools, and treat compliance as a patient care priority.