Collaborative practice agreement

In the United States, a collaborative practice agreement (CPA) is a written instrument that sets out the medical duties a licensed health professional other than a physician may perform, the conditions attached to that work, and the part the physician takes in it. Nurse practitioners and other advanced practice registered nurses, physician assistants, pharmacists and, for specific delegated tasks, registered nurses practice under one.

The term carries two senses. Narrowly it names the instruments whose statutory titles are built on collaborative, collaboration or arrangement, one of four families of terms that state law uses. Broadly it stands for the whole class of instruments whatever a given state calls its own, among them the supervision agreement, the delegation agreement, the standard care arrangement, the prescriptive authority agreement and the written protocol. A 2026 survey of the 50 states, the District of Columbia and Puerto Rico found 57 distinct statutory or regulatory names across the three professions most often covered, and a term from the collaboration family in 64 of the state-and-profession combinations surveyed: 18 for nurse practitioners, 9 for physician assistants and 37 for pharmacists.

Collaborative practice agreements are creatures of state law. A state's medical practice act, together with the acts governing nursing, physician assistants and pharmacy, determines whether an agreement is required, who signs it, what it must contain, whether it is filed with or approved by a licensing board, and how many clinicians one physician may cover. There is no federal practice agreement; federal payment programs such as Medicare generally defer to state scope-of-practice law in determining whether a service was lawfully furnished.

The requirement has been a central subject of the scope of practice debate in American health policy. Between 2010 and 2026 a majority of states removed or reduced the agreement requirement for nurse practitioners while extending agreement-based authority to pharmacists. As a result, the number of professions practicing under such an instrument grew even as the number of states requiring one for any given profession fell.

Terminology

No single term is used nationally. A 2026 survey of the 50 states, the District of Columbia and Puerto Rico identified 57 distinct statutory or regulatory names for the instrument across the three principal professions. The names fall into four broad families. The family a state's term belongs to is generally a better guide to the substance of the requirement than the term itself:

• Collaboration. Terms built on collaborative, collaboration or arrangement: collaborative practice agreement, written collaborative agreement, collaborative practice arrangement, Ohio's standard care arrangement, Colorado's articulated plan, Vermont's formal collaborative provider agreement. These describe a relationship between two independently licensed professionals rather than a transfer of the physician's authority.
• Supervision. Supervisory practice agreement, written supervision agreement, supervision agreement. These place the second professional's work under the physician's license and, in most states, make the physician answerable for it.
• Delegation. Delegation agreement, written protocol, Utah's delegation of services agreement, Georgia's job description for physician assistants. These rest on the doctrine that a physician may delegate acts that are otherwise the practice of medicine, and the written instrument records what has been delegated.
• Prescriptive authority. Texas's prescriptive authority agreement and Kentucky's collaborative agreement for prescriptive authority cover only the writing of prescriptions, leaving the rest of the professional's scope to the general practice act.

Several states use a term from one family for a mechanism that belongs to another. Florida calls the nurse practitioner instrument a written protocol, although the underlying relationship is supervisory, and Mississippi recognizes a "board-approved protocol or standing order" for nurse practitioners. Terms are also reused across professions with different meanings: written protocol names the pharmacist instrument in Texas, Alaska, Mississippi and New Jersey, and the nurse practitioner and physician assistant instrument in Florida.

A related but distinct instrument, the medical director agreement, names a physician as the clinical authority for a facility or business, such as a medical spa, an urgent care clinic, an opioid treatment program or a home-care company, rather than for an individual clinician. All 52 jurisdictions surveyed recognize some form of it, and a practice may need both.

Legal basis

Practice agreements arise from three separate bodies of state law that do not always align.

The medical practice act defines the practice of medicine and the circumstances in which a physician may delegate parts of it. Delegation-family instruments derive directly from this authority; Michigan, for example, permits a licensee to delegate acts to a person otherwise unlicensed to perform them, subject to supervision.

The professional practice act for the second profession sets the conditions on that profession's own license. New York requires a nurse practitioner to have a written practice agreement with a collaborating physician for the first 3,600 hours of practice, and Virginia provides for a practice agreement covering both nurse practitioners and physician assistants.

Board rules supply most of the operative detail. The required contents of an agreement, the frequency of chart review, the retention period and any filing obligation are usually found in regulations of the board of medicine, board of nursing or board of pharmacy rather than in statute. North Carolina's requirements for nurse practitioners appear in the joint rules of its medical and nursing boards, and Massachusetts sets its collaborative drug therapy management requirements by regulation.

These three bodies of law can disagree, as when a nursing board rule permits what a medical board rule restricts, or the reverse. Practices in the affected state generally follow the more restrictive requirement, because either board may discipline its own licensee.

Contents

Required contents vary by state, but the elements recur across jurisdictions:

• the names, license numbers and addresses of the parties;
• the practice locations and settings the agreement covers;
• the categories of drugs the second professional may or may not prescribe, and any restriction on controlled substances;
• a plan for consultation and referral, including coverage when the physician is absent and, in some states, a named alternate physician;
• the method and frequency of chart review or quality assurance, and any requirement for periodic meetings;
• the term of the agreement, and a requirement that it be reviewed and signed annually;
• retention of the signed agreement at the practice site and, in some states, filing with a licensing board.

Texas requires a prescriptive authority agreement to state the parties' names, addresses and license numbers; the nature of each party's practice and its locations; the categories of drugs covered; and a plan for consultation, referral and emergency coverage. The agreement must be reviewed annually.

Filing practice differs sharply. Some states require the agreement only to be held at the practice site and produced on request; others require registration with a board before the professional may practice. Most states do not require the physician to be present on site, and agreements are commonly held with a physician at a different location. Critics and defenders of that arrangement, sometimes called remote collaboration, characterize it very differently.

By profession

Advanced practice registered nurses

The requirement for nurse practitioners has changed more than for any other profession. The National Council of State Boards of Nursing's 2008 APRN Consensus Model recommended that advanced practice registered nurses be licensed as independent practitioners without a required written agreement with a physician, and the Institute of Medicine's 2011 report The Future of Nursing recommended that nurses be permitted to practice to the full extent of their education and training.

The American Association of Nurse Practitioners classifies state practice environments as full, reduced or restricted, the last two turning on whether a career-long regulated agreement with a physician is required. Some states require an agreement only for a transitional period: Nebraska uses a transition-to-practice arrangement, and New York's agreement requirement lapses after 3,600 hours.

Physician assistants

Physician assistants practice under an agreement in most states, and the supervision family of terms predominates. Several states have moved from supervision to collaboration language. Maryland and Oregon use collaboration agreement. Others have replaced the individual agreement with a practice-level obligation: West Virginia uses a practice notification. Minnesota eliminated its physician-agreement requirement for experienced physician assistants, retaining a written practice agreement with the employing practice. Missouri uses a single collaborative practice arrangement covering both nurse practitioners and physician assistants. Florida sets the physician assistant requirement in its Medical Practice Act.

Pharmacists

Main article: Collaborative drug therapy management

For pharmacists the instrument authorizes collaborative drug therapy management (CDTM): initiating, modifying or discontinuing drug therapy, and ordering related laboratory tests, under a written agreement with a prescriber. Every jurisdiction surveyed except two now recognizes some form of it. California authorizes pharmacists to perform specified functions under protocol, Washington and Maine provide for collaborative drug therapy agreements by regulation and by statute, respectively, and the Centers for Disease Control and Prevention has published implementation guidance promoting the agreements as a means of adding pharmacists to care teams for chronic disease management.

Pharmacist agreements differ from the nursing and physician assistant instruments in that they are typically population- or condition-specific rather than general, and are often held with an institution rather than a named physician.

Other professions

A smaller number of states extend the mechanism further. Georgia uses a nurse protocol agreement permitting a registered nurse to order drugs and devices under physician protocol, and several states authorize registered nurses to administer specified treatments under a standing order or protocol without an individual agreement.

Names by jurisdiction and profession

The table lists the principal instrument each jurisdiction names for each of the three professions most often covered. A dash indicates that the jurisdiction does not name a specific instrument for that profession; where a jurisdiction names more than one, both appear. Names are those used in the governing statute or board rule as of September 2026. A name in the collaboration family is used in 64 of these combinations.

Jurisdiction	Nurse practitioner	Physician assistant	Pharmacist
Alabama	Standard Protocol	Supervisory Practice Agreement	CDTM Agreement
Alaska	-	Collaborative Plan	Written Protocol
Arizona	-	Written Supervision Agreement	Collaborative Practice Agreement
Arkansas	Collaborative Practice Agreement	Delegation Agreement	Collaborative Practice Agreement
California	Standardized Procedures	Practice Agreement	Collaborative Practice Agreement
Colorado	Articulated Plan	Supervisory Practice Agreement / Collaborative Agreement	Collaborative Pharmacy Practice Agreement
Connecticut	Supervisory Practice Agreement	Written Delegation Agreement	Collaborative Drug Therapy Management Agreement or Care Plan
Delaware	Collaborative Agreement	Supervisory Practice Agreement	Collaborative Pharmacy Practice Agreement
District of Columbia	-	Delegation Agreement	Collaborative Practice Agreement
Florida	Written Protocol	Written Protocol	Written Collaborative Pharmacy Practice Agreement
Georgia	Nurse Protocol Agreement	Job Description	Drug Therapy Modification Protocol
Hawaii	-	Supervisory Practice Agreement	Written Collaborative Agreement
Idaho	-	Supervisory Practice Agreement	Written Collaborative Pharmacy Practice Agreement
Illinois	Written Collaborative Agreement	Written Collaborative Agreement	-
Indiana	Written Collaborative Practice Agreement	Written Supervisory Agreement	Written Collaborative Practice Protocol
Iowa	-	Supervisory Practice Agreement	Written Collaborative Pharmacy Practice Agreement
Kansas	-	Supervisory Practice Agreement	Written Collaborative Practice Agreement
Kentucky	Collaborative Agreement for Prescriptive Authority	Supervisory Practice Agreement	Written Collaborative Care Agreement
Louisiana	Collaborative Practice Agreement	Supervisory Practice Agreement	Collaborative Drug Therapy Management Order Set
Maine	Supervisory Practice Agreement	Collaborative Agreement	CDTM Agreement
Maryland	-	Collaboration Agreement	Prescriber-pharmacist Agreement
Massachusetts	Written Collaborative Arrangement	Supervisory Practice Agreement	Collaborative Practice Agreement
Michigan	Delegation Agreement	Written Practice Agreement	Delegation Agreement
Minnesota	Collaborative Agreement	Written Practice Agreement	Written Collaborative Practice Agreement
Mississippi	Board-approved Protocol or Standing Order	Written Practice Protocol	Written Protocol
Missouri	Collaborative Practice Arrangement	Collaborative Practice Arrangement	-
Montana	-	Supervisory Practice Agreement	Written Collaborative Pharmacy Practice Agreement
Nebraska	Transition-to-practice Arrangement	Written Collaborative Agreement	Written Practice Agreement
Nevada	-	Written Supervisory Agreement	Collaborative Practice Agreement
New Hampshire	-	Written Collaboration Agreement	Collaborative Pharmacy Practice Agreement
New Jersey	Written Joint Protocol	Written Supervision Agreement	Written Protocol
New Mexico	-	Supervisory Practice Agreement	Written Guidelines or Protocol
New York	Written Practice Agreement	Supervisory Practice Agreement	Collaborative Drug Therapy Management Framework
North Carolina	Collaborative Practice Arrangement	Supervisory Practice Agreement	Written Collaborative Practice Agreement
North Dakota	-	-	Collaborative Practice Agreement
Ohio	Standard Care Arrangement	Supervision Agreement	Consult Agreement
Oklahoma	Supervision, Collaboration, and Referral Plan	Written Practice Agreement	Written Collaborative Practice Agreement
Oregon	-	Collaboration Agreement	CDTM Protocol
Pennsylvania	Collaborative Agreement / Prescriptive Authority Collaborative Agreement	Written Agreement	Collaborative Agreement
Puerto Rico	Written Collaborative Agreement	Supervisory Practice Agreement	Protocol
Rhode Island	-	Supervisory Practice Agreement	Written Collaborative Practice Agreement
South Carolina	Written Practice Agreement	Scope of Practice Guidelines	Collaborative Practice Agreement
South Dakota	Written Collaborative Agreement	Written Practice Agreement	Protocol
Tennessee	Collaborative Practice Agreement	Supervisory Practice Agreement	Collaborative Pharmacy Practice Agreement
Texas	Prescriptive Authority Agreement	Prescriptive Authority Agreement / Supervisory Practice Agreement	Written Protocol
Utah	-	Delegation of Services Agreement	Collaborative Pharmacy Practice Agreement
Vermont	Formal Collaborative Provider Agreement	Written Practice Agreement	Written Collaborative Practice Agreement
Virginia	Practice Agreement	Practice Agreement	Written Collaborative Agreement
Washington	-	Supervisory Practice Agreement / Collaboration Relationship	Collaborative Drug Therapy Agreement
West Virginia	Written Collaborative Agreement	Practice Notification	Collaborative Pharmacy Practice Notification
Wisconsin	Collaborative Arrangement	Written Collaborative Agreement	Delegation Agreement
Wyoming	-	Supervisory Practice Agreement	Collaborative Practice Agreement

Ratios and other limits

Many states cap the number of clinicians one physician may cover. Texas limits a delegating physician to seven full-time-equivalent advanced practice registered nurses and physician assistants combined, with exceptions for medically underserved areas and facility-based practice. Other states set the limit by headcount rather than full-time equivalents, count nurse practitioners and physician assistants separately, or set no numeric limit at all.

Further conditions commonly attached to an agreement include a geographic limit on the distance between the physician and the practice site; a requirement that the physician practice in a related specialty; a minimum frequency of on-site visits; a percentage of charts subject to review; and a minimum number of hours of experience before the professional may hold an agreement or practice without one.

Because the physician's participation is a condition of the second professional's licensure, the agreement usually carries a fee. A market has developed in which physicians contract to serve as the collaborating, supervising or delegating physician for practices in which they do not otherwise work. Critics describe these arrangements as a payment for a signature that produces no clinical oversight; defenders describe them as the mechanism that allows clinics in areas without a resident physician to operate at all.

Policy debate

The requirement is contested, and the arguments are largely economic and evidentiary rather than technical.

The Federal Trade Commission has argued that mandatory physician-supervision requirements can raise costs and restrict competition without a corresponding safety benefit, and has urged states to scrutinize them. The Institute of Medicine reached a similar conclusion on access grounds, and nursing organizations argue that the requirement bears no relation to the individual professional's competence and is a barrier to practice in rural and underserved areas.

The American Medical Association and other physician organizations oppose removing the requirement, arguing that differences in the length and content of training justify physician-led teams and that patients may not distinguish between clinician types.

A separate line of criticism accepts the requirement in principle but questions its administration: agreements that are signed and filed but never acted on, chart-review obligations that are not met, and physicians who cover the statutory maximum number of clinicians across several states. This critique is made by participants on both sides of the scope-of-practice question, since an unenforced requirement supplies neither the oversight its defenders claim nor the access its opponents seek.

See also

• Scope of practice
• Medical guideline
• Mid-level practitioner
• Nurse practitioner
• Physician assistant
• Collaborative drug therapy management

External links

• State Practice Environment - American Association of Nurse Practitioners
• APRN regulation - National Council of State Boards of Nursing
• Practice agreement glossary by state and statutory name - Practice Agreement