An NP collaborative agreement is only as good as the clauses your state’s rule requires. Those clauses are specific. Texas wants monthly documented meetings and an annual review. Missouri wants chart review every fourteen days. Pennsylvania wants a named substitute physician and an insurance amount. Ohio wants a written process for disagreements. A generic template misses most of them.
This post walks through those clauses for eight states, using the statute or board rule for each. It does not cover what each physician title means, which is in medical director vs. supervising vs. collaborating physician, or who is liable when something goes wrong, which is in collaborating physician liability. It covers the document itself.
Each state names the document differently
The agreement goes by a different name in each of the eight states here, and the name tells you which rule governs it. Texas calls it a prescriptive authority agreement, the mechanism by which a physician delegates to an APRN the authority to order or prescribe drugs or devices [22 Tex. Admin. Code § 222.5]. Pennsylvania calls it a prescriptive authority collaborative agreement, for a CRNP who will prescribe and dispense [49 Pa. Code § 21.285]. Missouri calls it a collaborative practice arrangement [Mo. Rev. Stat. § 334.104]. Ohio calls it a standard care arrangement [Ohio Rev. Code § 4723.431]. Florida calls it an established protocol [Fla. Stat. § 464.012]. North Carolina calls it a collaborative practice agreement [21 NCAC 36 .0810]. Virginia calls it a practice agreement [Va. Code § 54.1-2957]. Tennessee requires protocols between the supervising physician and the nurse practitioner [Tenn. Comp. R. & Regs. 0880-06-.02].
Use your state’s term in the title of the document, so anyone reading it knows which rule it was written to satisfy.
The eight jurisdictions side by side
This table covers only the provisions we read in the cited sections. A blank in our reading is not proof that a state has no rule on that point. Check your board for anything not listed.
| Jurisdiction | Document | Review cycle | Chart review or meetings | Filing, notice or retention |
|---|---|---|---|---|
| Texas | Prescriptive authority agreement | At least annually, dated and signed | Chart review in a number the parties set; documented meetings at least once a month | Make available to the requesting licensing board by the third business day; the APRN keeps a copy for two years after termination |
| Pennsylvania | Prescriptive authority collaborative agreement | At least every 2 years or whenever changed | Must state when and how often the physician personally sees the patient | Copy filed with the Bureau of Professional and Occupational Affairs; CRNP notifies the board in writing when it is updated or terminated |
| Missouri | Collaborative practice arrangement | Duration must be stated | At least 10 percent of charts every fourteen days; 20 percent of controlled substance charts every fourteen days | Physician advises the board within 30 days of any change and at each license renewal |
| Ohio | Standard care arrangement | Date of most recent review must appear | Random chart review at least annually under the quality assurance rule | Employer keeps the current copy; nurse notifies the board of the collaborating physician within 30 days |
| North Carolina | Collaborative practice agreement | At least yearly, with a dated signature sheet | Monthly meetings for the first six months; quality improvement meetings at least every six months | Meeting records available for the previous five calendar years |
| Florida | Established protocol | Not stated in the sections cited | Not stated in the sections cited | Kept on site; physician files notice within 30 days of entering and of ending the protocol |
| Virginia | Practice agreement | Periodic review and revision, under joint board regulations | Health record review at a frequency the parties set | Evidence of the agreement provided to the boards on request |
| Tennessee | Protocols | Reviewed and updated biennially | Not covered in this post | Kept at the practice site and available to the boards |
Identity clauses: who, where and what may be prescribed
Every agreement starts by naming the parties, and several states want more than a name. Texas requires the name, address and all professional license numbers of the parties, the nature of the practice and its locations or settings [22 Tex. Admin. Code § 222.5]. Missouri requires complete names, home and business addresses, zip codes and telephone numbers of both the physician and the nurse, plus a list of all other offices where the physician authorized the nurse to prescribe [Mo. Rev. Stat. § 334.104]. Missouri also requires a list of all other written practice agreements of both parties [Mo. Rev. Stat. § 334.104].
The drug clause is next. Texas requires the agreement to identify either the types or categories of drugs or devices that may be ordered or prescribed, or those that may not [22 Tex. Admin. Code § 222.5]. Pennsylvania requires the categories of drugs from which the CRNP may prescribe or dispense, and the specialty in which the CRNP is certified [49 Pa. Code § 21.285]. Tennessee requires the protocols to account for all protocol drugs by appropriate formulary and to be specific to the population seen [Tenn. Comp. R. & Regs. 0880-06-.02].
For a med spa or weight loss program, this is where a template fails you. A template written for primary care tends to list antibiotics and antihypertensives. Your agreement should list what your nurse practitioner actually prescribes on your menu, and it should match the services you advertise.
Missouri adds a clause that lands in your lobby. The arrangement must require a prominently displayed disclosure statement at every office where the nurse prescribes, telling patients they may be seen by an advanced practice registered nurse and have the right to see the collaborating physician [Mo. Rev. Stat. § 334.104]. The geography rules that sit alongside it are in Missouri puts your collaborating physician on a map.
Chart review and meeting clauses are where agreements get tested
The review clause sets the standard you will be measured against, and some states require proof that the review happened.
Texas requires a quality assurance and improvement plan that includes chart review, with the number of charts set by the APRN and the physician, and periodic meetings [22 Tex. Admin. Code § 222.5]. Those meetings must be documented, must cover patient care and referrals, and must take place at least once a month in a manner determined by the physician and the nurse [Tex. H.B. 278 (2019)]. That monthly standard applies to agreements entered into on or after September 1, 2019, when H.B. 278 took effect [Tex. H.B. 278 (2019)].
Missouri sets the numbers in statute. The agreement must provide that the nurse submits at least ten percent of charts for review every fourteen days, and that the physician reviews at least twenty percent of the charts in which the nurse prescribes controlled substances every fourteen days [Mo. Rev. Stat. § 334.104]. The physician must produce evidence of the chart review when the board asks [20 CSR 2150-5.100].
Ohio’s quality assurance rule requires periodic random chart review, including prescribing patterns, at least annually, an opportunity to discuss feedback after the review, and a process for patient evaluation of care [Ohio Admin. Code 4723-8-05]. North Carolina requires monthly meetings during the first six months of a new agreement, and quality improvement meetings at least every six months, with signed and dated records [21 NCAC 36 .0810]. For nurse practitioners working as part of a patient care team, Virginia leaves the frequency of health record review to the nurse and the patient care team physician, but the agreement must provide for it [Va. Code § 54.1-2957].
Write the review clause as a number and a calendar. “Periodic review” invites an argument. “Ten charts on the first and third Monday” can be checked.
Coverage, emergency and disagreement clauses
Physicians take vacations and get sick. Your agreement has to say who covers.
Pennsylvania requires the agreement to identify at least one substitute physician who will provide collaboration when the collaborating physician is unavailable [49 Pa. Code § 21.285]. If alternate physician supervision will be used, Texas requires the agreement to designate one or more alternate physicians who may supervise on a temporary basis and take part in the quality assurance meetings [22 Tex. Admin. Code § 222.5]. Ohio requires a plan for coverage of patients during emergencies or planned absences of either the nurse or the physician [Ohio Admin. Code 4723-8-04].
Emergencies and referrals need their own clause. Texas requires a plan for patient emergencies and a general plan for consultation and referral [22 Tex. Admin. Code § 222.5]. Ohio’s statute requires criteria for referral and a process for the nurse to obtain a consultation [Ohio Rev. Code § 4723.431]. Virginia requires provisions for input from appropriate providers in complex clinical cases, patient emergencies and referrals [Va. Code § 54.1-2957].
Ohio adds a clause worth copying everywhere: a process for resolution of disagreements regarding matters of patient management [Ohio Admin. Code 4723-8-04]. Even where your state does not require it, write one. Name who decides, how fast, and how the decision is recorded.
Review, filing and termination clauses
Several of these rules require periodic review, and the paperwork around the agreement carries deadlines.
- Review on a schedule. Texas requires the agreement and any amendments to be reviewed at least annually, dated and signed [22 Tex. Admin. Code § 222.5]. North Carolina requires review at least yearly, acknowledged by a dated signature sheet appended to the agreement [21 NCAC 36 .0810]. Pennsylvania requires review and update at least every two years or whenever the agreement changes [49 Pa. Code § 21.285]. Tennessee requires protocols to be reviewed and updated biennially [Tenn. Comp. R. & Regs. 0880-06-.02].
- File or notify on time. In Florida, the physician files notice with the board within 30 days of entering a protocol with an APRN, and within 30 days after ending it [Fla. Stat. § 458.348]. In Missouri, the physician advises the board within 30 days of any change and at each license renewal [20 CSR 2150-5.100]. In Ohio, the nurse notifies the board of the collaborating physician’s identity within 30 days after starting practice [Ohio Admin. Code 4723-8-04]. In Pennsylvania, the CRNP notifies the board in writing when the agreement is updated or terminated [49 Pa. Code § 21.285].
- Keep it where the rule says. Florida requires the protocol to be maintained on site where the APRN practices, unless the APRN is registered and practicing under section 464.0123 [Fla. Stat. § 464.012]. Pennsylvania requires it at the CRNP’s primary practice location [49 Pa. Code § 21.285]. North Carolina requires it in each practice site [21 NCAC 36 .0810]. Ohio requires the employer to keep the current copy [Ohio Rev. Code § 4723.431].
- Produce it fast. Texas requires the agreement to be made available to the requesting licensing board no later than the third business day after the request arrives [22 Tex. Admin. Code § 222.5].
- Retain it after it ends. A Texas APRN who is a party keeps a copy until the second anniversary of termination [22 Tex. Admin. Code § 222.5]. Ohio nurses keep prior arrangements for three years [Ohio Admin. Code 4723-8-04].
Two more clauses deserve a line in any Texas agreement. A party notified that the respective licensing board is investigating them must immediately notify the other party [22 Tex. Admin. Code § 222.5]. And no party may by contract waive, void or nullify any provision of the rule or of sections 157.0512 or 157.0513 of the Occupations Code [22 Tex. Admin. Code § 222.5]. Pennsylvania also requires the agreement to specify the amount of professional liability insurance that covers the CRNP [49 Pa. Code § 21.285]. The filing mechanics there are in Pennsylvania files your CRNP agreement.
When a new agreement is required
Operators often assume one agreement follows the nurse practitioner. In Ohio it does not always. A new standard care arrangement must be executed when the nurse is employed at a different or additional organization or practice, and engages in practice with a collaborating physician or podiatrist outside of the primary employing organization [Ohio Admin. Code 4723-8-04]. If your nurse practitioner is employed by a hospital and also works in your clinic with a collaborating physician outside that hospital, plan for two documents.
Missouri handles extra sites inside the document itself. The arrangement must list all other offices or locations where the collaborating physician authorized the nurse to prescribe [Mo. Rev. Stat. § 334.104]. Update that list before your nurse practitioner starts prescribing at a new site.
What the statutes leave to you
Your agreement also needs business terms: the physician’s pay, the notice period for ending the relationship, and who tells patients and the board on the last day. Texas says the agreement may include other provisions agreed to by the APRN and physician, and is not required to describe the exact steps for each condition, disease or symptom [22 Tex. Admin. Code § 222.5].
MDside’s position: the collaborating physician is paid a fixed fee for defined duties and time. Pay is never tied to revenue or prescription volume, and the physician keeps clinical authority over the protocols. We also recommend naming a covering physician from day one, setting a termination notice period long enough to sign a successor, and stating who notifies the board. Our collaborating physician service is built on that structure.
What this means for you
Pull your current agreement and check it clause by clause against your state’s rule, starting with chart review, meetings, backup coverage and the review date. Add the clauses your state lists that the template skipped, such as Missouri’s lobby disclosure or Pennsylvania’s insurance amount. Put every filing and notice deadline on a calendar with an owner. If your nurse practitioner works in more than one state or setting, confirm whether each needs its own document.
References
- 22 Tex. Admin. Code § 222.5, prescriptive authority agreement. Texas Board of Nursing, amended effective October 17, 2019, as published by Cornell LII. Link
- Tex. H.B. 278 (2019), amending Tex. Occ. Code § 157.0512(e) and (f). Texas Legislature, enrolled version, effective September 1, 2019. Link
- Fla. Stat. § 464.012, licensure of advanced practice registered nurses. Florida Legislature, 2026 Florida Statutes. Link
- Fla. Stat. § 458.348, formal supervisory relationships and protocols. Florida Legislature, 2026 Florida Statutes. Link
- 49 Pa. Code § 21.285, prescriptive authority collaborative agreements. Pennsylvania State Board of Nursing, code current through September 5, 2026. Link
- Mo. Rev. Stat. § 334.104, collaborative practice arrangements. Missouri Revisor of Statutes, read November 2026. Link
- 20 CSR 2150-5.100, collaborative practice arrangement with nurses. Missouri State Board of Registration for the Healing Arts, as published by Cornell LII. Link
- Ohio Rev. Code § 4723.431, standard care arrangements. Ohio General Assembly, effective April 9, 2025. Link
- Ohio Admin. Code 4723-8-04, standard care arrangement. Ohio Board of Nursing, effective March 26, 2026. Link
- Ohio Admin. Code 4723-8-05, quality assurance for standard care arrangements. Ohio Board of Nursing, read November 2026. Link
- 21 NCAC 36 .0810, quality assurance standards for a collaborative practice agreement. North Carolina Board of Nursing, amended effective June 1, 2021. Link
- Va. Code § 54.1-2957, licensure and practice of advanced practice registered nurses. Virginia General Assembly, read November 2026. Link
- Tenn. Comp. R. & Regs. 0880-06-.02, supervision of nurse practitioners. Tennessee Board of Medical Examiners, as published by the Tennessee Secretary of State. Link
Frequently asked questions
What must be included in an NP collaborative agreement?
It depends on the state. Texas lists minimum contents: parties and license numbers, practice settings, drug categories, consultation and referral, emergencies, communication, and a quality assurance plan with chart review and monthly meetings. Missouri, Pennsylvania and Ohio publish their own lists. Start from your state’s statute or board rule, then add business terms such as notice periods and coverage.
How often must a collaborative agreement be reviewed?
Texas requires review at least annually, and North Carolina at least yearly with a dated signature sheet. Pennsylvania requires review at least every two years or whenever the agreement changes. Tennessee requires protocols to be reviewed and updated biennially. Virginia’s statute calls for periodic review and revision of the practice agreement under regulations the Boards of Medicine and Nursing adopt jointly.
Does a collaborative agreement have to be filed with the state board?
Some states require filing or notice, and the deadlines are short. Pennsylvania requires a copy filed with the Bureau of Professional and Occupational Affairs. Florida requires the physician to file notice within 30 days of entering or ending a protocol. Missouri requires the physician to notify the board within 30 days of any change, and Ohio requires the nurse to report the collaborating physician within 30 days of starting practice.
How many charts does a collaborating physician have to review?
Missouri sets it in statute: at least ten percent of charts every fourteen days, and twenty percent of charts with controlled substance prescriptions every fourteen days. Texas lets the APRN and physician set the number, but requires documented monthly meetings. Ohio requires random chart review at least annually. Write your number into the agreement so a board can check it.
Do I need a new collaborative agreement if my NP works at two practices?
In Ohio, yes when both conditions are met: the nurse is employed at a different or additional organization or practice, and engages in practice with a collaborating physician or podiatrist outside of the primary employing organization. Missouri requires the arrangement to list every other office where the nurse may prescribe. Confirm your state’s rule first.
This is general information, not legal advice. Rules vary by state and change. Confirm your own facts with counsel.