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“... icate, MyTMB access, CME audit or registration of prescriptive delegation, please include your name and license number and email us at Registrations@tmb.state.tx.us.
Location/Delivery Address:1801 Congress Avenue, Suite 9.200Austin, TX 78701
Mailing Address:P.O. Box 2018 Austin, TX ... ”
“... hich the license holder has conceded eminence and authority, and
the confines of the institution or program that recommended the license holder.
The holder of a Conceded Eminence License must pay the same fees and meet all other procedural requirements for issuance and renewal of the license as a p ... ”
“... or institution.
Public health medicine includes:
prescriptive authority for public health purposes,
preventive interventions,
diagnosis and treatment of communicable and vaccine preventable diseases,
pharmacological interventions for smoking cessation and contraception, and
other clinical preventiv ... ”
“... terhead and over the signature of the appropriate authority to make this request for the entity. Your request should identify the subsection of Section 151.002(a)(5), listed above, under which your organization qualifies, as well as the name and email address for the contact person who will be makin ... ”
“... register with the TMB if the physicians delegate prescriptive authority to PAs or APNs.
Senate Bill 406 (2013), requires a prescriptive authority agreement be in place between a physician and a PA or APN that has been delegated prescriptive authority.
Eligibility requirements for physicians ... ”
“... described by Section 104.003 shall designate the authority under which the title is used or the college or honorary degree that gives rise to the use of the title.
Therefore, if an acupuncturist wishes to use the title “doctor” the acupuncturist must clearly indicate to all where he or ... ”
“... o prescribe controlled substances and to register prescriptive delegation for Physician Assistants and Advanced Practice Nurses with the Texas Medical Board.
Physician Assistants with Temporary Licenses pending Medical Board approval will still be required to file a Prescriptive Delegation Form with ... ”
“... and/or the Board's rules; and exercising the authority to cancel, revoke, restrict, suspend or otherwise limit the license of any acupuncturist upon proof of violation.
Mission
The Texas State Board of Acupuncture Examiners’ mission is to protect and enhance the public's health, safety, a ... ”
“... ;If you do not have a license, have the licensing authority in the country where your acupuncture school is located submit a letter to you regarding eligibility to practice as an acupuncturist, in a sealed envelope, with the licensing authorities seal stamped across the outside flap.
Relicensure Ap ... ”
“... te renewal process. The Board does have the authority to conduct audits and inspections at clinics to ensure compliance with all requirements and regulations pertaining to registered pain clinics, including audits of CME training as required.
Documentation of CME courses shall be made a ... ”
“... the public or any person.
It does not include the authority to
practice clinical medicine,
prescribe dangerous drugs or controlled substances, or
delega ... ”
“... count to access the “Online Supervision and Prescriptive Delegation System”, the same username and password will work.)
Change of Address
Now that there is an online option for licensees to update their mailing and practice addresses, the hard copy Change of Address forms w ... ”
“... of APRNs or PAs to whom a physician may delegate prescriptive authority?
Is there a waiver if a physician wants to delegate prescriptive authority to more than seven full time equivalent APRNs and PAs?
How many delegating physicians may one APRN or PA have?
Do the requirements for types of pr ... ”
“... at is in good standing for purposes of entering a prescriptive authority agreement?
Do I have to disclose information regarding investigations and discipline? If so, to whom must this information be disclosed
What must be included in a prescriptive authority agreement?
Can we skip conducti ... ”
Description: TMB Bulletin Fall 2000
Document: ... n parties, if possible, and to apply a regulatory authority in an evenhanded manner based on the facts of the specific license or disciplinary action. We are sometimes limited by legislated statutes and we use Board rules for clarification of procedures and conduct. We are bound by certain legislati ...
Description: TMB Bulletin Fall 2006
Document: ... pdating and essentially rewriting Board Rule 170: Authority of Physician to Prescribe for the Treatment of Pain. A resource group was formed after initial attempts at drafting a document were met with numerous and diverse opinions from the public and physicians. The group consisted of representative ...
Description: TMB Bulletin Fall 2001
Document: ... physician, dentist, or chiropractor. SB 1166: PA Prescriptive Authority Allows physician to delegate prescriptive authority to up to three PAs or APNs at an alternate site, and does not require that the alternate site must be rural. Provides a process for obtaining a waiver of these requirements . ...
Description: TMB Bulletin Fall 2004
Document: ... eness and Efficiency
S.B. 104 provides stronger authority and more accountability for TMB to identify and discipline physicians who fail to meet the expected standards of professional behavior or competence. TMB has implemented and utilized new rules, procedures, and processes to more aggressively ...
Description: TMB Bulletin Fall 2009
Document: ... and ad
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of statutes and regulations relating to prescriptive
delegation, including recent changes.
Under the Medical Practice Act, Texas Occupa
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tions Code, and Chapter 193 of the Board rules,
physicians may delegate prescriptive authority to
PAs and APNs. This authority includes prescrib
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in ...
Description: TMB Bulletin Fall 2007
Document: ... o violation, there is no investigation. Statutory Authority Sections 164.051 and 164.052 of the Occupations Code spell out the violations for which TMB may deny licensure or discipline a licensee. Here they are paraphrased; the full statutory language is at http://tlo2.tlc.state.tx.us/statutes/oc.to ...
Description: TMB Bulletin Fall 2008
Document: ... conform with biennial registration. Chapter 169, Authority of Physicians to Supply Drugs: amendments to 169.2, Definitions, updates name of Texas Medical Board. Chapter 171, Postgraduate Training Permits: amendments to 171.3, Physician-in-Training Permits, updates the name of the Texas Medical Boar ...
Description: TMB Bulletin Fall 1997
Document: ... e enacted a significant expansion of notification authority. Under Section 81.051 of the Health and Safety Code, "a health care professional shall notify the partner notification program when the health care professional knows the HIV+ status of a patient and the healt h care professional has actual ...
Description: TMB Bulletin Fall 1998
Document: ... , Persons With Criminal Backgrounds; Chapter 169, Authority of Physicians to Supply Drugs; Chapter 180, Rehabilitation Orders; Chapter 188, Complaint Procedure Not ification; Chapter 190, Disciplinary Guidelines; Chapter 191, District Review Committees; Chapter 196, Voluntary Surrender of a Medical ...
Description: TMB Bulletin Fall 1999
Document: ... , Persons With Criminal Backgrounds; Chapter 169, Authority of Physicians to Supply Drugs; Chapter 180, Rehabilitation Orders; Chapter 188, Complaint Procedure Not ification; Chapter 190, Disciplinary Guidelines; Chapter 191, District Review Committees; Chapter 196, Voluntary Surrender of a Medical ...
Description: TMB Bulletin Fall 2005
Document: ... year was assigning to the Texas Medical Board the authority to use administrative orders in its disciplinary process. Administrative orders are presently being used in a limited fashion in cases involving CME and medical records violations to allow physicians to pay a fine in lieu of participating i ...
Description: TMB Bulletin June-July 2003
Document: ... ement and reissuance of a license.
Chapter 169, Authority of Physicians to Supply Drugs. Rule review and amendments to 169.1-.5 and 169.7 for general cleanup of the chapter. Chapter 171, Postgraduate Training Permits. Amendments to 171.1 and 171.2 regarding reporting requirements relating to p ...
Description: TMB Bulletin Spring 2005
Document: ... . House is not permitted to supervise or delegate prescriptive authority to a physician assistant or advanced practice nurse; he may not prescribe controlled substances and must surrender his controlled substances certificates; he must enroll in the CPEP program (now the Center for Personalized Edu ...
Description: TMB Bulletin Spring 2006
Document: ... Nurses, to include elimination of registration of prescriptive delegation with the board, the addition of documentation of prescriptive delegation by the physician, and the elimination of the Advisory Committee on Prescriptive Delegation Waiver requests. The full board rules may be viewed and/or dow ...
Description: TMB Bulletin Spring 2007
Document: ... for the physician to remain abstinent. Using this authority, the board can quickly move to protect the public if a physician relapses. If a licensed physician knows someone who may have a problem that could impair the ability to safely practice medicine and the person is "a continuing threat to the ...
“... 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 Examiner ... ”
What is the "corporate practice of medicine"?
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.
“... 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 informati ... ”
Is the Prescription Monitoring Program (PMP) check mandated each and every time a physician or authorized delegate prescribes one of the four scheduled drug types?
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/.
“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 opinio ... ”
What are the general rules related to AAs/CRNAs?
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.
“... ing 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. ”
How does a PA register a supervising physician with the Board?
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.
“... n be terminated using the Online Supervisions and Prescriptive Delegation Registration System. ”
How does a PA terminate a supervising physician relationship?
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 cir ... ”
Can a PA sign a prescription for controlled substances?
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.
“... /31/2010, registration by physicians of delegated prescriptive authority to PAs or APNs is required. ”
Does delegation of prescriptive authority to a PA or APN have to be registered with the TMB as well?
Effective 1/31/2010, registration by physicians of delegated prescriptive authority to PAs or APNs is required.
“... 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. ... ”
How many physician assistants can a physician supervise?
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. ... ”
How many PAs can a physician delegate prescriptive authority to?
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.
“... s can be done through the Online Supervisions and Prescriptive Delegation Registration System. ”
How soon does a PA need to update the Board about a change in supervising physicians? What about an addition?
Within 30 days of the change or addition. This can be done through the Online Supervisions and Prescriptive Delegation Registration System.
“... ed above. However, the Board does have inspection authority, and owners of clinics that have not been properly registered can be investigated. ”
Who does not need to register a pain management clinic?
Regulations regarding the registration and operation of pain management clinics do not apply to the following settings:
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.
“... tificate renewal process. The Board does have the authority to conduct audits and inspections at clinics to ensure compliance with all requirements and regulations pertaining to registered pain clinics, including audits of CME training as required. ”
What are the continuing education requirements for pain management clinics?
Per Board Rule 195.4(e), the medical director or owner/operator of the pain management clinic, must on annual basis, ensure all personnel are properly licensed and, if applicable, have the requisite training to include 10 hours of continuing medical education (CME) annually in the area of pain management. This CME requirement applies to all personnel providing medical services to the patients (including, but not limited to: PAs, x-ray techs, phlebotomists, RNs, MAs, etc.). Office staff, such as managers, janitors, etc. who do not provide medical services, would not be required to meet the CME requirement, but would need to be listed in response to a pain clinic audit which requires listing all clinic personnel for that clinic. Documentation of the completed CME course shall be required to be made available upon request by Board Staff, including, but not limited to, during an on-site audit of the clinic, or during the certificate renewal process. The Board does have the authority to conduct audits and inspections at clinics to ensure compliance with all requirements and regulations pertaining to registered pain clinics, including audits of CME training as required.
“The answer to the question depends on the practice setting. In facility-based hospital practices and in practices that serve medically underserved populations, there are no limitations. In all other practice settings, one physician may delegate to no more than seven full time equivalent ... ”
Is there still a ratio for the number of APRNs or PAs to whom a physician may delegate prescriptive authority?
The answer to the question depends on the practice setting. In facility-based hospital practices and in practices that serve medically underserved populations, there are no limitations. In all other practice settings, one physician may delegate to no more than seven full time equivalent APRNs and PAs (1:7 FTEs).
“... onger exists. A physician may only delegate prescriptive authority to more than seven full time equivalent APRNs and PAs in facility based hospital practices and in practices that serve medically underserved populations. In all other settings and practice scenarios, the 1:7 FTE ratios ap ... ”
Is there a waiver if a physician wants to delegate prescriptive authority to more than seven full time equivalent APRNs and PAs?
No, the waiver process no longer exists. A physician may only delegate prescriptive authority to more than seven full time equivalent APRNs and PAs in facility based hospital practices and in practices that serve medically underserved populations. In all other settings and practice scenarios, the 1:7 FTE ratios applies.
“... imit to the number of physicians who may delegate prescriptive authority to an APRN or PA provided all requirements for such delegation are met. ”
How many delegating physicians may one APRN or PA have?
There is no limit to the number of physicians who may delegate prescriptive authority to an APRN or PA provided all requirements for such delegation are met.