The Collaboration Agreement Is What Lets an NP Prescribe Without a Physician in the Room

For telehealth businesses building distributed provider networks, understanding these arrangements is an important part of medical practice management. A company may have licensed providers, a functioning telehealth platform, and established prescribing workflows. However, it still needs to confirm that each provider has the authority to deliver the intended services in the jurisdictions where patients receive care.

The challenge becomes more complicated when a business operates across multiple states. Some states allow qualified nurse practitioners to practice without a physician collaboration agreement, while others require formal agreements or other supervisory arrangements. Physician assistants operate under state-specific rules, so evaluate each provider type separately rather than assuming one agreement covers everyone.

What Is a Collaboration Agreement?

A collaboration agreement is a formal arrangement that defines the professional relationship between a healthcare provider and a collaborating or supervising physician.

Depending on the state, the agreement may be called a collaborative practice agreement, prescriptive authority agreement, practice agreement, or another legally defined document.

Its purpose is to establish how the provider can practice within the applicable legal framework, including the clinical activities they may perform, their prescribing authority, and the responsibilities of any required collaborating or supervising physician.

For example, a nurse practitioner in a state that requires physician collaboration may be authorized to evaluate patients and prescribe certain medications under a valid agreement and within the provider's applicable scope of practice.

However, a collaboration agreement does not independently grant every possible clinical or prescribing privilege. The provider must also satisfy the licensing, professional scope, registration, and other requirements applicable to the services being delivered.

What Does a Collaboration Agreement Typically Include?

Although the specific requirements vary by jurisdiction, agreements may address several recurring areas:

• Provider identification: The names, credentials, professional licenses, and practice information of the participating providers.
• Scope of practice: The clinical activities the NP or PA may perform within their professional authority.
• Prescribing authority: The medications or categories of medications the provider is authorized to prescribe, including applicable restrictions.
• Physician consultation: The circumstances in which the provider should consult with or refer a patient to the collaborating physician.
• Clinical oversight: Any required chart reviews, quality assurance activities, or periodic meetings.
• Communication procedures: How the providers exchange relevant patient information and coordinate care.
• Emergency procedures: How the practice handles situations requiring additional clinical attention or escalation.
• Agreement maintenance: Requirements for reviewing, renewing, modifying, or retaining the agreement.

Not every state requires every one of these elements. Some jurisdictions prescribe detailed agreement contents, while others allow greater flexibility or do not require a physician collaboration agreement for certain qualified practitioners.

The key question for a telehealth business is whether the arrangement meets the requirements for the specific provider, services, and jurisdictions involved.

Texas: A Detailed Example of a Prescriptive Authority Agreement

Texas provides a useful example of how specific collaboration and prescribing requirements can be structured.

Under Texas Occupations Code, Chapter 157, a physician may delegate specified prescribing authority to an appropriately qualified advanced practice registered nurse or physician assistant through a prescriptive authority agreement, subject to the statute's requirements.

The agreement is more than an informal understanding that a physician will be available when needed. Texas law specifies what the agreement must contain and establishes ongoing responsibilities for the participating providers.

What Texas Requires in the Agreement

For an agreement subject to the applicable requirements of Chapter 157, the written document must identify the participating providers and their practice information, describe the nature of the practice, and specify the categories of drugs or devices that may or may not be prescribed.

It must also address consultation, referrals, emergencies, communication, and the quality assurance process.

The Texas Medical Board's prescribing and supervision guidance explains that the required quality assurance process includes chart reviews and periodic meetings between the participating providers.

Several operational requirements are particularly important:

The Texas Medical Board explains that the statute does not establish one universal number or percentage of charts that must be reviewed. Instead, the participating providers determine the appropriate amount while maintaining adequate supervision under the applicable requirements.

For a telehealth company coordinating multiple providers, these requirements create ongoing operational responsibilities rather than a one-time document-signing exercise.

The organization needs a reliable way to keep agreements current, coordinate required meetings, document reviews, and identify when an agreement or provider relationship needs attention.

Why Collaboration Agreement Requirements Vary by State

A collaboration agreement that meets one state's requirements does not automatically authorize a provider to practice in another.

States establish different rules governing professional scope of practice, physician involvement, prescribing authority, and the arrangements required between physicians and other healthcare professionals.

These differences matter for nurse practitioners because some states allow qualified NPs to practice independently, while others require physician collaboration or supervision for certain activities.

Full, Reduced, and Restricted Practice Authority

Nurse practitioner practice authority is often described using three broad categories.

These categories help explain general differences between states, but they do not replace the actual statutes and licensing board rules.

A state may allow an NP to perform certain clinical activities independently while imposing separate conditions on prescribing. Specific medications, provider credentials, and practice settings may also affect the applicable requirements.

For telehealth operators, the practical approach is to evaluate the provider's actual authority rather than relying solely on a state's general practice-authority classification.

California: How NP Practice Authority Has Changed

California illustrates why healthcare businesses need to monitor regulatory changes rather than assume collaboration requirements remain the same indefinitely.

Assembly Bill 890 established new pathways allowing certain qualified nurse practitioners to practice without the standardized procedures previously required under California's traditional NP practice framework.

The California Board of Registered Nursing's Assembly Bill 890 guidance explains that the legislation created two categories of nurse practitioners with different practice-setting and qualification requirements.

The 103 NP and 104 NP Categories

Under California's framework, the two categories have different conditions.

California's guidance also explains that the traditional NP practice pathway remains available. An NP who has not qualified for an applicable independent practice pathway may still need to operate under standardized procedures.

This creates an important distinction for telehealth businesses: two nurse practitioners licensed in the same state may have different practice requirements depending on their qualifications and regulatory status.

Rather than treating every California NP as subject to the same collaboration rules, an organization should confirm the individual provider's authority and the setting in which care will be delivered.

103 NP - Practice within a qualifying group setting

A qualified 103 NP may practice without standardized procedures within the applicable statutory scope while working in a qualifying group setting that includes at least one physician and surgeon.

104 NP - Independent practice under additional conditions

The 104 NP category provides a pathway for qualified nurse practitioners to practice without standardized procedures outside the group setting required for 103 NPs, within their authorized population focus and subject to additional eligibility requirements.

California's categories are not interchangeable. Evaluate qualification, certification, practice setting, and prescribing requirements separately.

Are Collaboration Agreements Different for Physician Assistants?

Yes. Although nurse practitioners and physician assistants may perform overlapping clinical activities, they are different professions governed by their own licensing and scope-of-practice frameworks.

A state's decision to grant certain nurse practitioners independent practice authority does not automatically extend the same authority to physician assistants.

Similarly, a state may use different terminology or establish different requirements for PA supervision, collaboration, practice agreements, or prescribing delegation.

The practical differences can involve:

• Whether a formal written agreement is required
• The physician's role in the professional relationship
• The PA's authorized scope of practice
• Prescribing and medication-related restrictions
• Required consultation or chart-review arrangements
• Documentation and reporting obligations

Texas is an example of a jurisdiction where the prescriptive authority agreement framework under Chapter 157 expressly addresses both advanced practice registered nurses and physician assistants.

However, even when a statute addresses both professions, you still need to consider each profession's individual licenses and other applicable professional requirements.

A telehealth company should therefore maintain provider-specific compliance records rather than assuming an NP agreement can be reused for a PA without further review.

Why Collaboration Agreements Matter for Telehealth Businesses

A telehealth business may have providers located in several states, patients distributed across the country, and clinical services delivered through both synchronous and asynchronous workflows.

That flexibility creates operational opportunities, but it also complicates professional licensing and scope-of-practice requirements.

The U.S. Department of Health and Human Services explains in its telehealth licensure guidance that healthcare professionals must meet applicable licensure requirements in the state where they are located and must be licensed or otherwise legally permitted to practice in the state where the patient is located.

For telehealth businesses, this means the patient's location is essential to determining whether a provider may deliver care.

However, it is not the only relevant factor. The provider's location, professional license, practice setting, prescribing authority, and other applicable requirements may also affect the arrangement.

One Provider, Multiple State Requirements

Consider a nurse practitioner who provides telehealth services to patients in three different states.

The NP may be qualified to practice independently in one jurisdiction while needing an additional collaborative or supervisory arrangement to provide the intended services in another.

A third state may impose separate licensing or prescribing conditions.

The telehealth platform may look identical in all three situations, but the legal authority underlying the clinical workflow may differ.

This is why provider assignment should account for more than availability. The organization needs to confirm that the selected provider is authorized to deliver the intended service to the patient in the applicable jurisdiction.

The Collaboration Agreement vs. CPOM: Two Different Requirements

Collaboration agreements and the corporate practice of medicine (CPOM) doctrine both affect healthcare business structure, but they address different legal questions.

CPOM concerns the circumstances in which a corporation, non-physician, or other entity may own or control a medical practice or employ physicians.

A collaboration agreement, by contrast, addresses the professional relationship and responsibilities between a physician and another healthcare provider when applicable law requires that arrangement.

A telehealth company may need to address both issues at the same time.

For example, a business may work with a properly structured physician-owned medical practice while that practice employs or contracts with NPs who require physician collaboration for certain services.

The clinical entity's ownership structure does not automatically establish that each NP or PA has the authority required to provide care.

Likewise, a valid collaboration agreement does not resolve separate CPOM restrictions that apply to the business.

Federal Exceptions: What the VA Rule Actually Changes

Although state law generally governs collaboration and scope-of-practice requirements, certain federal healthcare systems operate under their own statutory and regulatory frameworks.

A useful example is the Department of Veterans Affairs.

In 2016, the VA issued a final rule concerning advanced practice registered nurses that established a framework under which qualifying APRNs in specified roles could receive full practice authority within VA employment, notwithstanding conflicting state restrictions on that authority.

The rule addressed certified nurse practitioners, clinical nurse specialists, and certified nurse-midwives. It did not extend the same full-practice-authority framework to every APRN role or to physician assistants, and it preserved applicable controlled-substance limitations.

The distinction matters because federal authority in the VA system does not establish a nationwide exemption for private telehealth businesses.

A privately operated telehealth company cannot rely on the VA's internal practice-authority framework to bypass state collaboration or prescribing requirements that otherwise apply to its providers.

The Operational Challenge: An Agreement Is Not a One-Time Task

For a small telehealth practice, managing a few provider agreements may appear straightforward. As the organization adds more clinicians, services, and jurisdictions, however, agreement administration can become a recurring operational responsibility.

A business may need to monitor whether agreements remain current, which physicians are responsible for collaboration, whether required meetings and chart reviews occur, and how changes in provider status affect the clinical workflow.

These responsibilities are closely connected to telehealth provider onboarding, because adding a new clinician involves more than creating a platform account and assigning patients.

Before the organization assigns clinical responsibilities, it must establish a provider's professional authority and required relationships.

How Bask Health's Model Relates to Collaboration Agreements

Bask Health provides infrastructure for digital healthcare businesses, including patient management, EMR and e-prescribing tools, and access to clinical provider networks.

Bask's plans and platform capabilities describe its doctor portal, EMR, e-prescribing, patient experience tools, and broader telehealth management infrastructure. The platform also offers provider-network options for businesses building digital healthcare services.

Integrated Clinical Networks and Provider Relationships

For brands using an integrated clinical network, the medical group is responsible for its professional operations, including ensuring that its providers have the authority required for the services they deliver.

When applicable law requires physician collaboration, supervision, or prescribing delegation, responsible parties must establish and maintain those arrangements.

Working with an established clinical network may reduce the amount of provider recruitment and coordination a brand needs to manage independently. However, access to that network does not automatically establish that every possible NP or PA arrangement is appropriate for every service and state.

Brands should confirm which provider types, clinical services, and geographic locations their platform and clinical-network arrangements support.

What About Brands Bringing Their Own Clinical Network?

A telehealth brand that uses its own clinical network must account for the professional relationships and legal requirements that apply to its providers.

That may involve coordinating collaboration agreements, verifying prescribing authority, maintaining provider licenses, and ensuring that the clinical entity follows applicable supervision and documentation rules.

Integrating the network with a technology platform does not transfer those professional responsibilities to the software itself.

For businesses evaluating Bask Health, the distinction is between the infrastructure used to manage the patient journey and the legal authority under which clinicians provide care.

Bask provides technology and access to clinical infrastructure, but the responsible medical group and qualified healthcare counsel should still confirm the applicable provider arrangements.

FAQs

What Is a Collaboration Agreement?

A collaboration agreement is a formal arrangement defining the professional relationship between a healthcare provider and a collaborating or supervising physician.

Depending on the jurisdiction, it may address scope of practice, prescribing authority, consultation, clinical oversight, and other responsibilities.

The terminology and legal requirements vary by state and provider type.

Is a Collaboration Agreement Required in Every State?

No. Some states permit qualified nurse practitioners to perform authorized professional activities without a physician collaboration agreement, while others require collaboration or supervision for certain services.

Physician assistant requirements are distinct and must be reviewed separately.

A provider's license, professional qualifications, practice setting, prescribing authority, and applicable jurisdiction all matter when determining the required arrangement.

Can an NP Prescribe Without a Physician Physically Present?

An NP may be authorized to prescribe without a physician physically present, depending on the applicable laws, the provider's qualifications, and any required collaborative or supervisory arrangements.

However, a physician's absence from the room does not automatically mean the NP has independent prescribing authority.

In states requiring a prescriptive authority agreement, the provider must satisfy the applicable agreement and professional requirements.

How Is a Collaboration Agreement Different From CPOM?

CPOM primarily concerns medical practice ownership and control, while a collaboration agreement governs a professional relationship involving physician collaboration, supervision, or delegated authority.

A telehealth business may need to address both requirements, but satisfying one does not automatically satisfy the other.

What Happens if an NP Practices Without a Required Collaboration Agreement?

An NP who practices or prescribes without a required agreement may be acting outside the authority permitted under applicable state law.

Depending on the circumstances, this can create professional licensing, prescribing, and other legal or regulatory exposure for the participating providers and potentially the organizations involved.

The consequences depend on the jurisdiction, the activity performed, and the applicable regulatory framework.

Does a Collaboration Agreement Automatically Authorize Controlled-Substance Prescribing?

No. Controlled-substance prescribing may be subject to additional state and federal requirements, including professional authority, registration, prescribing limitations, and applicable telehealth restrictions.

A collaboration agreement cannot independently authorize prescribing that is otherwise prohibited or outside the provider's professional authority.

How Does Bask Health Handle Collaboration Agreements for NPs and PAs?

Bask Health provides access to telehealth infrastructure and clinical-network options that can support businesses using different types of licensed healthcare providers.

When an integrated medical group provides clinical services, it must establish and maintain any professional arrangements required for its providers.

Brands using their own clinical networks must ensure their providers meet applicable licensing, scope-of-practice, collaboration, and prescribing requirements.

In either case, confirm the specific arrangements with the responsible clinical organization and qualified healthcare counsel.

Conclusion

A collaboration agreement can define the relationship that allows a nurse practitioner or physician assistant to practice and prescribe within the authority permitted by applicable state law. Still, it is not required for every provider in every jurisdiction.

For telehealth businesses, the central challenge is understanding which providers need these arrangements, what the agreements must contain, and how those requirements interact with professional licensing, prescribing authority, and the business's clinical operating model.

Bask Health provides connected technology and clinical-network infrastructure for businesses building digital healthcare services. By reviewing the provider options and operational capabilities in Bask's plans, founders can evaluate how the platform fits their intended care model while ensuring the responsible clinical organization maintains the professional arrangements required in each applicable jurisdiction.

References

1. Texas Legislature. (n.d.). Occupations Code, Chapter 157: Authority of Physician to Delegate Certain Medical Acts. https://tcss.legis.texas.gov/resources/OC/htm/OC.157.htm

2. Texas Medical Board. (n.d.). Prescribing and Supervision. https://www.tmb.texas.gov/apply-renew/physician/prescribing-and-supervision

3. California Board of Registered Nursing. (n.d.). Assembly Bill 890. https://www.rn.ca.gov/practice/ab890.shtml

4. U.S. Department of Health and Human Services. (2024). Getting Started With Licensure. https://telehealth.hhs.gov/licensure/getting-started-licensure

5. Department of Veterans Affairs. (2016). Advanced Practice Registered Nurses. Federal Register, Final Rule. https://www.federalregister.gov/documents/2016/12/14/2016-29950/advanced-practice-registered-nurses