The corporate practice of medicine is a legal doctrine, which generally prohibits corporations, entities or individuals (i.e. non-physicians) from practicing medicine.

A general summary of the corporate practice of medicine doctrine is that it prohibits physicians from entering into partnerships, employee relationships, fee splitting, or other situations with non-physicians where the physician's practice of medicine is in any way controlled or directed by, or fees shared with a non-physician. Generally, physicians may enter into independent contractor arrangements with non-physicians. However, whether an independent contractor situation exists is a question of law and attendant facts.

Section 165.156 of the Medical Practice Act makes it unlawful for any individual, partnership, trust, association or corporation by use of any letters, words, or terms, as an affix on stationery or advertisements or in any other manner, to indicate the individual, partnership, trust, association or corporation is entitled to practice medicine if the individual or entity is not licensed to do so.

Section 164.052(a)(13) of the Medical Practice Act authorizes disciplinary action against any licensee for impersonation of a licensed practitioner or permitting another to use his license to practice medicine. Section 164.052(a)(17) authorizes disciplinary action against a practitioner for aiding or abetting, directly or indirectly, the practice of medicine by non-licensed individuals or entities.

Beginning in 2011, the Texas Legislature enacted laws authorizing certain types of hospitals and specific hospital districts to directly hire physicians.

Because of the highly technical aspects of this doctrine, a physician should consult with private counsel regarding any actual or contemplated arrangement. Please be advised that the Board staff is not authorized to provide private legal advice.

The following case law/legal authority may be helpful in the analysis and are available from any local law library or private counsel:

a. Garcia v. Texas State Board of Medical Examiners, 384 F.Supp. 434 (W.D. Texas 1974);

b. F.W.B. Rockett v. Texas State Board of Medical Examiners, 287 S.W.2d 190 (Tex. Civ.App.- San Antonio 1956, writ ref'd n.r.e.);

c. Watt v. Texas State Board of Medical Examiners, 303 S.W.2d 884 (Tex. Civ. App.- Dallas 1957, writ ref'd n.r.e.);

d. Flynn Brothers, Inc. v. First Medical Associates, 715 S.W.2d 782 (Tex. Civ. App.- Dallas 1986, writ ref'd n.r.e.)

e. Woodson v. Scott & White Hospital, 186 S.W.2d 720 (Tex. App. 1945, writ ref'd w.o.m.)

f. Tex. Atty. Gen. Op. JM-1042 (1989)

g. Tex. Atty. Gen. Op. WW-278 (1957).

h. Tex. Atty. Gen. Op. JM 369 (1985)

i. Tex. Atty. Gen. Op. DM-138 (1992)

j. Tex. Atty. Gen. Op. M-551 (1970)

k. The Medical Practice Act, Texas Occupations Code Annotated, Title 3, Subtitle B as amended, section 162.001.

l. The Medical Practice Act, Texas Occupations Code Annotated, Title 3, Subtitle B as amended, section 162.001.

m. The Medical Practice Act, Texas Occupations Code Annotated, Title 3, Subtitle B as amended, 151.055.

n. Occupations Code, section 102.001.

Yes. Prior to and each and every time a physician or advanced practice professional (such as a physician assistant or advanced practice registered nurse acting under a physician’s delegated authority) prescribes opioids, benzodiazepines, barbiturates, or carisoprodol, the patient’s prescribing history must be reviewed by the physician or advanced practice professional issuing the prescription.  For providers seeking information on how to access the PMP, please review Pharmacy Board PMP information at https://www.pharmacy.texas.gov/pmp/.

At this time, only physician applicants can use the Form Y to expedite an application. Should this change, notification will be posted.

Texas requires physicians to professionally use the name under which they are licensed by the Texas Medical Board. Using any other name may confuse or mislead the public and could be considered by the Board to be unprofessional conduct. A physician who wishes to change his or her professional name must use the Application for Name Change.

You must provide us with a statement that gives an explanation of your request, a completed Name Change Application form and a notarized copy of the legal document(s) that granted your name change, i.e. marriage license, divorce decree etc.

No.  However, changes in mailing or practice addresses can now be updated online in most situations.  For those license types that cannot use the online system, a Change of Address form is available, but not required.  Information on the new Change of Address system is available at: http://www.tmb.state.tx.us/page/change-address

The authority to delegate is found in Chapter 157 of the Texas Occupations Code, and Title 22 of the Texas Administrative Code, Section 193. A physician is allowed to delegate certain duties to a qualified and properly trained person acting under the physician’s supervision:

1) if in the opinion of the delegating physician the act can be properly and safely performed by the person to whom the medical act is delegated;
2) the act is performed in its customary manner; and
3) the performance of the act by the delegate is not in violation of any other statute.

It is clear that AAs can be delegated certain tasks under Chapter 157. The question is the extent allowable of such delegation. The key provision that needs to be examined is likely “not in violation of any other statute.”

Although the Nursing Act describes what a CRNA can do in regard to anesthesia, there is overlap of regulation of CRNAs between the Medical Board and Nursing Board. CRNAs are subject to physician delegation under the Medical Practice Act. The delegating physician can limit what a CRNA is allowed to provide under a Prescriptive Authority Agreement (PAA) or Standing Order, despite what may be allowed under Nursing Board rules and regulations.

The level of supervision required for any AA (or any delegated provider) is determined based on training, knowledge, and experience, as determined by the physician. For CRNAs, whether any level of physician supervision is required will depend upon those same factors, in addition to applicable federal and state statutes, regulations, bylaws, and ethical standards, if any. However, AAs and CRNAs cannot practice independently and require physician delegation. A hospital or facility can set their own standards, policies, etc., related to delegation and supervision as long as it does not violate Chapter 157, board rules, or other applicable federal and state statutes and regulations. Although AAs most commonly work under an anesthesiologist physician, any physician may supervise and delegate to AAs; however, the standard of care must be met and the delegating physician remains responsible for the AA’s actions.

One difference between an AA and CRNA is the ability to order and prescribe dangerous and controlled substances to patients for anesthesia and anesthesia-related services. Under section 157.058, a CRNA pursuant to the physician’s order and in accordance with facility policies or bylaws may select, obtain, and administer those drugs appropriate to accomplish the order. The physician’s order for anesthesia or anesthesia-related services is not required to specify a drug, dose, or administration technique.

As previously stated, the Nursing Act describes what a CRNA can do in regard to anesthesia. However, the delegating physician or facility can limit what a CRNA is allowed to provide under a PAA or Standing Order, despite what may be allowed under Nursing Board rules and regulations.

While AAs are not allowed to select drugs, determine dose, or administration technique for anesthesia or anesthesia-related services without specification by the supervising physician through an order, they perform many of the other same key duties performed by CRNAs. These duties include conducting preoperative physical exams, administering medications, evaluating and responding to life-threatening situations, setting up external and internal monitors, and implementing general and site-specific anesthetic techniques.

Another area of concern relates to handing-off patient care from CRNAs to AAs. RNs have the authority to delegate certain nursing tasks to unlicensed individuals; however, a CRNA and AA do not have any specific delegation authority concerning anesthesia tasks. A physician has the authority to delegate the process of anesthesia-related patient care, including the transfer or hand-off of care from a CRNA to an AA through an order (standing or patient-specific) or protocol. A CRNA or AA cannot set-up or independently delegate a hand-off or step-down process.

While the Nursing Act places responsibility for patient hand-off on a CRNA, if the physician orders a hand-off process from CRNA to AA, and this is memorialized in orders, protocols, etc., then the CRNA does not have the authority to determine the AA is not competent. The reason is that the physician has already made the determination of competency under Chapter 157.001.

Because the CRNA’s authority also arises through the delegating physician, and is not independent of that physician, a CRNA cannot override a physician Order related to this hand-off scenario. If this hand-off became an issue, the CRNA would have a defense (absolute) because the physician has already determined the competency of the AA to accept this patient. 

You can register a new supervising physician through the Online Supervisions and Prescriptive Delegation Registration System. Please note that this is a 2 step process and that the supervising physician must complete the registration.

The addition of a new supervising physician does not terminate any other supervision that is currently in place. Any current supervising physician relationship can be terminated using the Online Supervisions and Prescriptive Delegation Registration System.

Yes, the PAs supervising physician must delegate prescriptive authority allowing a PA to sign prescriptions for controlled substances, also called scheduled drugs, as well as Dangerous Drugs. However, PA's are generally limited to Schedules III – V (Schedule IIs are allowed in very limited circumstances). All prescription drugs that are not controlled substances fall into the category of "dangerous drugs." Physician assistants with prescriptive authority must have their own DEA numbers to prescribe controlled substances. In addition, physician assistants must have the name of their current delegating physician authorizing prescriptive authority on file with DEA.

Please note: Under Senate Bill 195, the requirement for controlled substances registration (CSR) with the Texas Department of Public Safety (DPS) was eliminated as of September 1, 2016.

Effective 1/31/2010, registration by physicians of delegated prescriptive authority to PAs or APNs is required.

There is no limitation to the number of PAs or APNs a physician may supervise. However, a physician may only delegate prescriptive authority to a maximum of seven PA's or APN's, or their full-time equivalent.  The only exception relates to supervision and prescriptive delegation to a medically underserved population or in facility based practice.

A physician may delegate prescriptive authority to a maximum of seven PA's or APN's, or their full-time equivalent. There are some statutory exceptions for prescriptive delegation to a medically underserved population or in facility based practice. Refer to Board rule 193.

Within 30 days of the change or addition. This can be done through the Online Supervisions and Prescriptive Delegation Registration System.

Regulations regarding the registration and operation of pain management clinics do not apply to the following settings:

• a medical or dental school or an outpatient clinics associated with a medical or dental school;
• a hospital, including any outpatient facility or clinic of a hospital;
• a hospice established under 40 TAC §97.403 (relating to Standards Specific to Agencies Licensed to Provide Hospice Services) or defined by 42 CFR §418.3;
• a facility maintained or operated by this state;
• a clinic maintained or operated by the United States;
• a nonprofit health organization certified by the board under Chapter 177 of this title (relating to Certification of Non-Profit Health Organizations);
• a clinic owned or operated by a physician who treats patients within the physician's area of specialty who personally uses other forms of treatment, including surgery, with the issuance of a prescription for a majority of the patients.

Note: The TMB cannot give legal advice. Please consult an attorney if you have questions regarding whether or not your clinic meets one of the exemptions listed above. However, the Board does have inspection authority, and owners of clinics that have not been properly registered can be investigated.