In Alabama, a physician may collaborate with or supervise CRNPs, nurse midwives and PAs totaling no more than 360 hours a week, which the rule calls nine full-time equivalents. Ala. Admin. Code r. 540-X-8-.12 counts hours rather than people, and it counts the physician’s collaborative and supervisory agreements in other states toward the same cap.
If you are hiring a medical director who serves clinics in several states, that last clause is the one to read twice. The text below is the Alabama Administrative Code as published on October 1, 2026.
The cap is 360 hours, and other states count
Rule 540-X-8-.12(1) defines one full-time equivalent as “a person/persons collectively working forty hours a week, excluding time on call.” Nine of them make 360 hours. The Board of Nursing’s parallel rule, r. 610-X-5-.05, says the same, and r. 540-X-7-.26 applies the same combined cap from the PA side.
Three features matter to an operator:
- It is a combined cap. The physician “shall not collaborate with or supervise any combination” of CRNPs, CNMs and PAs exceeding 360 hours per week.
- It reaches outside Alabama. The physician must disclose to the Board “all collaborative and supervisory agreements to which the physician is a party, including collaborative and supervisory agreements in other states,” and the cap is “inclusive of collaborative and supervisory agreements existing in other states.”
- One person is counted once. Agreements with the same individual in multiple states “shall only be counted once.”
The Joint Committee may approve additional positions on request, weighing physician availability, risk to patients and the complexity of procedures. A physician at the cap may ask in writing for a transitional allowance of up to 45 days to orient an incoming CRNP. Health department employees are exempt.
A physician who already signs for many nurse practitioners elsewhere may have little or no room left for yours. Ask for the number before you sign.
Above four FTEs, new CRNPs get monthly review
Rule 540-X-8-.12(1)(a) adds a second threshold. A physician collaborating with more than four FTEs per week “shall engage in documented quality assurance review with each CRNP every month for six (6) months following the commencement of a collaborative practice with a new CRNP.”
A busy director therefore owes your new CRNP six monthly reviews, each documented, before the quarterly schedule begins.
Quarterly quality assurance is more than a signature
Every collaborating physician must “complete quarterly quality assurance with each CRNP” under r. 540-X-8-.08(5)(f). The definition in r. 540-X-8-.01(13) says what that means: a documented evaluation of the CRNP’s clinical practice against defined quality outcome measures, using a meaningful sample of patient records, with a summary of findings, conclusions and recommendations.
The definition ends with a sentence aimed at a common shortcut: “The physician’s signature on the patient record does not constitute quality improvement monitoring.”
The written protocol must specify the plan, and the review must include “a meaningful sample of medical records plus all adverse outcomes” (r. 540-X-8-.08(8)(g)). The Board’s guidance page adds that its rules “do not require a specific percentage of charts,” that someone other than the physician or CRNP may pull the data, and that each documented review must carry a patient identifier.
The physician keeps the quality assurance documentation for the life of the collaboration and for three years after it ends. Failure to maintain or produce required documentation on request is a ground for terminating the Board’s approval of the collaboration under r. 540-X-8-.15(1)(f).
A covering physician must be approved in advance
When the collaborating physician is not readily available, oversight passes to a covering physician “who is readily available, who is pre-approved by the Board of Medical Examiners, and who is familiar with these rules” (r. 540-X-8-.08(2)). A colleague who agrees informally to take calls is not a covering physician under this rule.
The definition in r. 540-X-8-.01(18) limits who qualifies. The covering physician must be a member of the same medical practice, practice group or multidisciplinary medical team, or of the same or similar practice specialty as the collaborating physician. The collaborating physician certifies to the Board at least annually that each covering physician still agrees to serve, and reports a covering physician’s termination within ten days.
If the collaborating physician leaves without warning and for good, a previously approved covering physician may serve as temporary collaborating physician for up to 60 days while a new commencement is filed. Without an approved covering physician on file, you have no bridge.
What the rule expects, in one table
| Requirement | Frequency or limit | Rule |
|---|---|---|
| Combined CRNP, CNM and PA hours per physician, all states | 360 per week | r. 540-X-8-.12(1) |
| Quality assurance review with each CRNP | Quarterly | r. 540-X-8-.08(5)(f) |
| Quality assurance with a new CRNP, if physician is above four FTEs | Monthly for six months | r. 540-X-8-.12(1)(a) |
| Covering physician certification to the Board | At least annually | r. 540-X-8-.08(2) |
| Notice of covering physician termination | Within 10 days | r. 540-X-8-.08(2) |
| Temporary collaborating physician after a permanent absence | Up to 60 days | r. 540-X-8-.08(3) |
| Collaborative practice CME for the physician | Every 48 months | r. 540-X-8-.04(6) |
| Retention of quality assurance and experience documentation | Duration plus three years | r. 540-X-8-.08(5) |
The physician must also hold a current, unrestricted Alabama license and have practiced at least three years, or at least one year with ABMS or AOA board certification, unless the Board waives it (r. 540-X-8-.04(1)). The on-site presence percentage for newer CRNPs and the twice-yearly remote site visits are in the same rule and are covered on the Alabama medical director page.
The protocol names every site and stays on file
Under r. 540-X-8-.08(8), the written protocol must identify all sites where the CRNP will practice and the physician’s principal practice site, be kept at each practice site, and be on file with both boards. It must include a formulary, a plan for emergency services, and the referral process.
Two closing paragraphs are written for arrangements like yours. Paragraph (9) says the physician “shall maintain independent medical judgment related to the practice of medicine at all times, irrespective of employment structure or business model.” Paragraph (10) deems all services to occur in the state where the patient is located, and holds the collaborating physician, covering physician and CRNP to Alabama rules for Alabama patients, including oversight, quality assurance review and record keeping.
Where MDside differs from common practice
Directorships are often sold by the signature, with no account of how many signatures the physician has already given. Alabama makes that a compliance question with a number attached. MDside’s position is that a physician’s collaborative and supervisory hours in every state should be totaled before an Alabama placement, and that an approved covering physician should be named at the outset. How we credential providers and how it works describe the process.
What this means for you
Before you sign with a collaborating physician, ask for their current weekly total of CRNP, CNM and PA hours in every state, in writing. Ask who the Board-approved covering physician is. Put the quarterly quality assurance dates on a calendar and keep the documented reviews where you can produce them. If the physician is above four FTEs, add six monthly reviews for each new hire. A med spa that expects a nurse practitioner to carry the clinical work depends on these filings staying current.
Frequently asked questions
How many nurse practitioners can a physician supervise in Alabama?
The limit is set in hours. Ala. Admin. Code r. 540-X-8-.12 caps a physician at a combined 360 hours per week, or nine full-time equivalents, across all CRNPs, certified nurse midwives and physician assistants. Agreements in other states count toward the cap. The Joint Committee may approve additional positions on request.
Do out-of-state agreements count toward Alabama’s collaborative practice cap?
Yes. Rule 540-X-8-.12(1)(b) requires the physician to disclose all collaborative and supervisory agreements, including those in other states, and makes the 360-hour cap inclusive of them. An individual CRNP, nurse midwife or PA who works with the same physician in more than one state is counted only once.
How often must an Alabama collaborating physician do quality assurance review?
Quarterly with each CRNP, under r. 540-X-8-.08(5)(f). A physician collaborating with more than four full-time equivalents must also review each new CRNP monthly for the first six months. The review must be documented against defined outcome measures. A physician’s signature on the chart does not count as quality assurance.
What is a covering physician in an Alabama collaborative practice?
An Alabama-licensed physician who agrees in writing to provide oversight when the collaborating physician is absent. The covering physician must be pre-approved by the Board of Medical Examiners and be in the same practice, group or team, or the same or similar specialty. The collaborating physician certifies the arrangement to the Board at least annually.
What happens if the collaborating physician leaves suddenly in Alabama?
Under r. 540-X-8-.08(3), after an unanticipated, permanent absence a previously approved covering physician may be designated temporary collaborating physician for up to 60 days. During that period a new commencement naming a new collaborating physician should be submitted for approval. The provision depends on a covering physician having been approved beforehand.
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This is general information, not legal advice. Rules vary by state and change. Confirm your own facts with counsel.