Texas Med Spa Medical Director Requirements 2026: TMB Rules, Delegation & Supervision

Why Texas Med Spas Need a Medical Director

In Texas, procedures like Botox injections, dermal fillers, GLP-1 prescribing, laser treatments, and hormone therapy are medical acts. Under the Texas Occupations Code Chapter 164, only a licensed physician can perform or delegate these acts. When a physician delegates a procedure to an RN, NP, or PA, they remain fully responsible for the outcome — delegation does not transfer liability.

The title "medical director" and "supervising physician" are functionally equivalent under Texas law. Both describe the licensed MD or DO who establishes protocols, supervises delegated staff, and is accountable to the Texas Medical Board for everything performed at the practice. If your med spa does not have this person clearly identified, documented, and actively involved, you are operating outside the law.

What the January 2025 TMB Rule Changes Mean for You

In January 2025, the Texas Medical Board consolidated its delegation framework under 22 TAC Chapter 169, replacing the older §193.17 cosmetic procedure rules. The restructuring did not loosen standards — it clarified and centralized them. Key changes that directly affect med spas:

• Supervision and delegation requirements now apply uniformly across all medical spa services, not just cosmetic procedures
• Written protocol requirements are more explicitly defined, covering what must be documented and how long records must be retained
• Transparency requirements were strengthened — physician name and TMB license number must now be posted in all public areas and treatment rooms
• Pending legislation (SB 378 and HB 3749) could impose stricter on-site presence requirements as early as September 2026

If your protocols and supervision arrangements were set up before 2025, now is the time to review them against the updated Chapter 169 framework.

Qualifications: Who Can Serve as Medical Director

The requirements are clear and non-negotiable:

• Must be a licensed MD or DO with an active, unrestricted Texas license in good standing
• Cannot be under TMB disciplinary action or have license restrictions that prevent supervising the specific procedures offered
• Must be trained or familiar with each delegated procedure — the physician must be able to perform the act themselves per the standard of care
• Must have established a practitioner-patient relationship for the practice and maintain or oversee medical records

Nurse practitioners and physician assistants cannot serve as the medical director. They may perform delegated acts under a physician's supervision, but the MD or DO is always the delegating authority. This is a common point of confusion — and a common source of TMB investigations.

For a broader comparison of how medical director rules differ across states, see our guide to med spa medical director requirements.

22 TAC §169.26: The Core Supervision Standard

The practical question most Texas med spa operators ask is: how often does the medical director need to be physically present? The answer from 22 TAC §169.26 is nuanced:

• The physician must be physically present during the delegated act, OR
• The physician must be immediately available for consultation and able to see the patient in person if an adverse event occurs

Texas does not mandate a specific on-site visit schedule the way some other states do. What matters is documented, meaningful availability. A physician who signs protocols but is unreachable during procedures, or who serves as medical director for 20 locations across the state with no realistic availability, does not meet this standard — and the TMB has acted on exactly this scenario.

What "Immediately Available" Actually Means

The TMB interprets "immediately available" as the physician being reachable by phone and able to physically arrive at the practice within a reasonable timeframe to assess a patient in distress. If your medical director lives three hours away and sees patients at seven other practices on the same day, that arrangement will not survive scrutiny. Document how the physician will be reached, what the response time expectation is, and who covers when the primary medical director is unavailable.

Written Protocol Requirements

A signed, dated written protocol is required for every delegated procedure category. Under 22 TAC §169.26, each protocol must include:

• A clear description of what procedures are delegated
• How each procedure is to be performed
• Under what conditions the procedure may be performed (patient selection criteria)
• Required qualifications, training, and credentials of the person performing the delegated act
• The physician's availability and consultation procedure
• Contraindications and circumstances requiring physician involvement

Protocols must be kept on file and available for TMB inspection at any time. They should be reviewed and re-signed whenever procedures, staff, or regulatory requirements change. A protocol signed in 2021 that covers treatments your practice added in 2024 is a compliance gap.

Our SOP guide for med spas covers how to structure these documents and what level of detail regulators expect.

Delegation to RNs, NPs, and PAs

Texas allows physicians to delegate medical acts to a range of licensed professionals, but the scope varies by credential:

Registered Nurses (RNs)

RNs can perform delegated medical acts — including injectables — under a physician's written protocol and supervision. The Texas Board of Nursing governs nursing scope of practice; the TMB governs the physician's delegation authority. Both must be satisfied.

Advanced Practice Registered Nurses (APRNs / NPs)

APRNs can perform delegated acts under physician supervision. They have a broader scope than RNs but still require physician oversight for medical spa procedures in most practice settings. For a detailed breakdown, see our guide on who can inject Botox in Texas.

Physician Assistants (PAs)

PAs work under physician supervision per 22 TAC §185.14. In a med spa, a PA can perform delegated procedures within the scope established by the supervising physician's protocol. PAs cannot supervise other staff independently on the physician's behalf without explicit written authorization from the supervising physician.

Medical Assistants (MAs)

Medical assistants are not licensed to perform medical procedures in Texas, including injections. Delegating injectables to an MA — even with a physician in the building — is a TMB violation.

Transparency Requirements: What Must Be Posted

Texas med spas are required to post the following in all public areas and individual treatment rooms:

• The name and TMB license number of the delegating/supervising physician
• Notice of how patients can file complaints with the Texas Medical Board
• All staff performing delegated acts must wear ID badges showing their name and credentials

These are not suggestions — the TMB checks for them during inspections. A missing physician name posting is a quick citation that triggers deeper review.

TMB Enforcement Trends in 2025–2026

The Texas Medical Board has increased enforcement activity against med spas since 2024. Common patterns in recent actions:

• Ghost medical directors — physicians who sign contracts but have no real involvement in protocols or supervision
• No written protocols — or protocols that are unsigned, undated, or do not cover current procedures
• Inadequate chart review — no documentation showing the physician reviewed patient records or outcomes
• Unqualified delegation — procedures delegated to MAs or unlicensed staff
• Multi-location overextension — physicians listed as medical director at too many locations to provide meaningful oversight

Violations can result in fines starting at approximately $500 per violation, cease-and-desist orders, temporary practice closure, and TMB disciplinary action against the physician's license. For a full breakdown of compliance violations and their consequences, see our post on common med spa compliance violations.

Medical Director Liability in Texas

One of the most important points to understand: delegation does not transfer liability in Texas. Under Texas Occupations Code §164.053, the supervising physician remains responsible for all aspects of the delegated procedure and patient safety — even if a nurse or PA performed the treatment.

This means your medical director agreement, their level of involvement, and their insurance coverage all matter enormously. A physician who signs protocols but is never on-site and never reviews charts has the same liability exposure as one who is actively engaged — but without the documentation to defend themselves. Our guide on med spa medical director liability goes deeper on structuring these arrangements to protect both parties.

Staff Training Documentation

The medical director is responsible for ensuring that every person performing delegated acts has appropriate training. "Appropriate" in the TMB's view means documented — training certificates, competency checklists, and supervision logs. Verbal assurances that a nurse is trained do not satisfy the standard. See our resource on med spa staff training requirements for what documentation to maintain.

How Texas Compares to Other States

Texas takes a middle-ground approach to med spa oversight compared to other large markets. California has strict CPOM (Corporate Practice of Medicine) ownership rules and an aggressive Medical Board; Florida has a more prescriptive licensing structure through AHCA. Texas is more flexible on ownership structure and visit frequency — but this flexibility is not a license for minimal physician involvement. TMB enforcement has increased precisely because some operators misread Texas's less prescriptive rules as permissive. For a state-by-state breakdown, see our med spa regulations by state guide.