Texas NP Prescriptive Authority Agreement for Med Spas

Search for a "nurse practitioner collaborative agreement template" with Texas in mind and you land in the wrong vocabulary. Many states hand their nurse practitioners a collaborative or practice agreement. Texas does not. A Texas APRN who wants to order a neurotoxin, start a patient on a GLP-1 or write a testosterone prescription does it under a prescriptive authority agreement — usually shortened to PAA — signed with a delegating physician. The same instrument covers physician assistants who prescribe.

This guide is about that document and nothing else. It explains when a Texas med spa needs one, walks through the contents line by line, separates what our Texas sources say the law requires from what we recommend as practice, and then covers signing, maintenance and the failures that tend to surface when a Texas Medical Board complaint arrives. If you want the general shape of these agreements across states first, start with our national NP collaborative agreement template guide and come back here for the Texas translation.

What Is a Texas Prescriptive Authority Agreement, and Who Needs One?

Verdict: it is the written instrument through which a Texas physician delegates prescribing to an APRN or PA, and any APRN or PA who orders a prescription drug or device in your med spa needs a current one. Holding a nursing licence, an APRN credential or a DEA registration does not substitute for it. Our Texas nurse practitioner playbook puts it bluntly: without a current PAA, you cannot prescribe at the med spa even if you personally hold a DEA registration. The federal registration speaks to controlled substances; the agreement is what makes the prescribing lawful in Texas.

Why Texas needs the document at all comes down to its practice model. Texas is a restricted-practice state under the American Association of Nurse Practitioners' 2026 classification, which means career-long supervision, delegation or team management by another provider. No independent-practice pathway exists for an experienced NP, and every 2025 bill that would have loosened that died in committee. Authority in a Texas med spa therefore always flows from a physician, and the prescriptive authority agreement is the channel it flows through for prescribing.

Two layers: delegation to perform, a PAA to order

Texas splits the clinical work of a med spa into two questions that operators often run together. The first is who may perform a medical act — the injection, the infusion, the laser pass. Occupations Code §157.001 lets a physician delegate a medical act to a qualified and properly trained person under the physician's supervision, and the delegating physician remains responsible for the acts of the person performing them. The Texas Medical Board's rules at 22 TAC §§169.25–169.28 then govern how that delegation works for nonsurgical cosmetic procedures, which §169.25 treats as the practice of medicine.

The second question is who may order the drug or device. Our Texas SOP manual guide frames the division precisely: delegation authorises performing the act; ordering the drug is separate, and for a PA or APRN it comes through a prescriptive authority agreement. A med spa can have an immaculate set of protocols for its RN injectors and still have no lawful prescriber on the premises if the NP's agreement has lapsed.

The two layers meet at the patient evaluation. Under 22 TAC §169.26(c), before a delegated cosmetic procedure, a physician — or a PA or APRN acting under a physician's delegation — must establish the practitioner-patient relationship, maintain an adequate record, disclose who will perform the act and ensure someone trained in basic life support is on site. That is why the NP's agreement matters even on days when an RN does all the injecting: the NP who evaluates the patient and orders the toxin is exercising delegated prescriptive authority.

Who needs one, role by role

• Nurse practitioners and other APRNs — yes, for any prescribing or ordering. Our delegation matrix lists the authorising instrument as delegation plus a prescriptive authority agreement, with no independent route.
• Physician assistants — yes, for prescribing. The matrix pairs a delegation registered with TMB with a PAA to order the drug, citing Occupations Code §204.204 and §157.0512.
• Physicians (MD/DO) — no. They act on their own licence and are the delegating party, not the delegate.
• Registered nurses — no PAA. An RN injects as a delegate on a signed protocol plus a patient-specific order and cannot evaluate or order.
• Estheticians and medical assistants — no. Neither credential confers authority to prescribe or inject; an esthetician licence covers epidermal work only.

Why a national template needs translating for Texas

Generic NP agreement templates are usually written for states where a collaborating physician consults with a largely self-directed nurse practitioner. A Texas PAA sits inside a delegation regime instead, so the physician is not merely collaborating — they are the source of the prescribing authority and remain responsible for it. The practical difference shows up in three places: the agreement must describe what may and may not be prescribed rather than leaving scope to the NP's training; it must carry a quality assurance plan with a fixed monthly meeting; and the physician's total count of delegates is capped. A template that omits any of those has not been adapted to Texas, however polished it looks.

What Must a Texas Prescriptive Authority Agreement Include?

Verdict: our Texas sources quote Occupations Code §157.0512(e) for eight required elements — writing and signatures, parties, practice and locations, drug and device categories, consultation and emergency plans, communication, alternate physicians, and a quality assurance plan — plus an annual signed review. Everything beyond that list is best practice, and the list below labels which is which.

Read each line as a heading in the finished agreement. When an investigator requests the document, the fastest way to show compliance is a PAA whose sections map one-to-one onto the statute's items, followed by the practice-specific schedules that make it usable.

The categories clause carries the most weight

Item 4 is where most Texas agreements are won or lost, because it decides what the delegate may actually write. The statutory wording runs both ways — categories that may or may not be prescribed — so a good agreement includes an exclusions line as well as an inclusions list. Our Texas weight-loss guide gives the cautionary example: a PAA that predates a med spa's weight-loss programme and never mentions GLP-1s is not a document under which the APRN can lawfully write those prescriptions. Name classes the way the menu reads, and when the menu changes, change the schedule before the first prescription.

Controlled substances deserve their own line within that clause. Our Texas NP playbook notes that testosterone is a Schedule III controlled substance and that controlled substances are not automatically inside delegated authority. For a spa offering hormone therapy, the physician's delegation, the delegate's DEA registration, the facility's controlled-substance storage and logging, and the PAA's schedule authorisation all have to line up. If one is missing, the prescribing is not lawful.

The quality assurance plan is two obligations, not one

The QA plan is the part of the agreement that turns a signature into supervision, and our Texas sources describe two named components. Chart review comes first, and the statute leaves the number of charts to the physician and the delegate. The second is a meeting held at least once a month that covers patient care, changes in care plans and referral issues, and is documented. The Texas record in our regulations dataset says the same in short form: a PA or APRN acts under a written prescriptive authority agreement that requires quality-assurance chart review and meetings between the physician and the PA or APRN at least monthly.

Two points from our delegation rules guide save a lot of argument. First, the monthly cadence does not step down after a first year; the older monthly-then-quarterly scheme was repealed by HB 278 in 2019, and that bill also removed the face-to-face requirement. Second, no Texas rule fixes a chart-review percentage — a vendor who quotes a fixed ten or twenty percent as the law is inventing it. Pick your own number, write it into the agreement, and keep the record that proves you met it.

Who Signs a Texas Prescriptive Authority Agreement, and How?

Verdict: the delegating physician and the APRN or PA sign and date it, before the delegate's first prescription under it, and any alternate supervising physician should be named in the document itself. The practice is not a statutory party, but it is the entity a Board investigator asks for the file, so it should hold a complete, current copy.

Choosing the delegating physician

The physician is not just a counterparty — they remain responsible for the delegate's medical acts under §157.001, and inadequate supervision is a stand-alone disciplinary ground under Occupations Code §164.053(a)(8). Before signing, ask how many APRNs and PAs the candidate already holds agreements with. §157.0512(c) caps a physician at seven advanced practice providers, or the full-time equivalent, and a physician already at the limit cannot lawfully take on your NP no matter how well drafted your agreement is. Our medical director agreement guide makes the same point from the other direction: Texas does not cap how many med spas a physician can direct, but it does cap delegation.

A signing sequence that holds up

1. Fix the service menu first. List every drug class, device and controlled schedule the delegate will need, and every location where they will work. (Best practice.)
2. Draft against the §157.0512(e) items. Use the statute's elements as section headings so nothing is missing and a reviewer can find each one. (Texas requirement for the contents; the heading structure is best practice.)
3. Write the QA plan with numbers. State the chart-review number and method and the monthly meeting, and attach the log template. (Texas requirement for chart review and monthly documented meetings; the stated number is best practice.)
4. Name the alternates. Designate any alternate supervising physicians in the agreement rather than in an email. (Texas requirement.)
5. Sign and date. Physician and delegate sign; the date should precede the first prescription. (Texas requirement to sign and date; dating before first use is best practice.)
6. Diary the review. Put the annual review date and the first monthly meeting in the calendar the day the agreement is signed. (Annual review is a Texas requirement; the diary is best practice.)

Board paperwork that sits beside the agreement

For physician assistants, our Texas delegation rules guide lists two TMB items for the practice file: supervising physician approval for PAs under Occupations Code §204.205, and delegation registration and termination notices within 30 days under 22 TAC §169.5. This guide does not cover filing or notice steps for the prescriptive authority agreement itself. Confirm with the Texas Medical Board and the Texas Board of Nursing what, if anything, must be submitted for your arrangement before the delegate starts.

How Does the Agreement Fit Injectables, Weight Loss and Hormones?

Verdict: the PAA governs who may order each product on your menu, not who may physically administer it, so map every service line to a drug category in the agreement and then check the separate delegation that covers the person at the chair.

Neurotoxins and fillers

In a typical Texas injectables practice, the NP evaluates the patient and orders the toxin or the prescription product, and either the NP or a delegated RN injects. The agreement must therefore cover the products the NP orders, not the act of injecting, which runs through the physician's protocols and §169.26. If the NP is also the injector, the agreement and the protocol both need to be in force on the treatment date.

Who may inject at all is a different question with its own Texas answer: physicians; PAs and APRNs under delegation; and RNs as delegates on a patient-specific order. Esthetician and cosmetology licences authorise no injection. Our Texas Botox delegation rules guide works through each role and the supervision standard.

Weight-loss prescribing

GLP-1 programmes are where a stale agreement is most likely to show. Texas NPs prescribe GLP-1s, like other drugs, only under the PAA, and the APRN cannot pass delegated authority down to a medical assistant or other unlicensed staff — our weight-loss guide records that as the Texas Board of Nursing's stated position. Before launching a weight-loss line, add the GLP-1 drug class to the categories schedule, confirm the physician remains inside the seven-provider cap if you are adding prescribers to staff the programme, and make sure titration and follow-up decisions are documented by a prescriber rather than by the staff member running the scale. The rest of the programme — compounding sources, consent, telehealth — is covered in our Texas GLP-1 compliance guide.

Hormone therapy and other controlled substances

If testosterone or another controlled preparation is on the menu, treat the controlled-substance line of the agreement as its own mini-agreement. Name the schedules, tie them to the services, and check that DEA registration, storage and logging match. Our Texas hormone therapy and DEA guide covers the federal side; the PAA's job is to make the Texas authority explicit.

Services that need no prescribing at all

Not every service touches the agreement. Epidermal skin care by an esthetician does not involve prescribing. Cosmetic laser procedures are performed or delegated by a physician under protocol, and laser hair removal is certified by TDLR under a consulting physician; neither runs through prescriptive authority. Keep the PAA's categories honest: listing services the delegate will never order adds review burden without adding authority.

How Does the PAA Relate to the Medical Director Agreement?

Verdict: they are two documents with different jobs. The medical director agreement sets up the physician's overall relationship with the practice; the PAA carries the specific, statutorily required delegation of prescribing to one APRN or PA. One physician often holds both roles, which is exactly why the documents get merged — and why merging them causes trouble.

Our Texas medical director agreement guide covers the contract between the physician and the practice — compensation, scope of services, supervision structure, posting duties under Rule 169.28, termination — and we will not repeat it here. What matters for the PAA is where the two documents touch:

Three cross-checks keep the pair consistent. The chart-review number in the director agreement should match the one in each PAA, or the stricter of the two should govern. The locations in each PAA should match the sites the director agreement covers. And the name posted under Rule 169.28 — the delegating physician's name and licence number in public areas and treatment rooms — should be the physician who actually signed the agreements in force. A spa that changes directors without re-papering every PAA and replacing the posting has a gap an inspector can see from the waiting room.

What Are the Most Common Texas PAA Failures?

Verdict: the failures are rarely about missing clauses on day one. They are about agreements that stopped matching reality — the menu grew, the physician changed, the monthly meetings slipped — while the signed document sat in a drawer.

1. No current agreement at all. The NP holds a DEA registration and assumes that is enough. It is not; the PAA is the source of Texas prescribing authority.
2. A menu that outgrew the categories. GLP-1s, a new filler-related prescription product or a hormone line added without amending item 4. Prescriptions written outside the listed categories are written without authority.
3. Controlled substances covered by implication. A general clause and no schedule named, while the spa runs a testosterone programme.
4. A missed annual review. The agreement was signed once and never reviewed, dated and signed again. Our delegation rules guide calls this the item practices most often skip.
5. Meetings held but not documented. The physician and NP talk weekly by phone, and nothing records date, attendees or topics. A monthly meeting that cannot be shown is, for an investigator, a meeting that did not happen.
6. A chart-review clause with no number. "The physician will review charts periodically" cannot be audited. Texas leaves the number to the parties; leaving it blank is the parties' failure.
7. An over-extended physician. A delegating physician beyond seven advanced practice providers or the full-time equivalent across all their arrangements. The excess exposes every practice in the chain, however clean any single agreement looks.
8. Alternates who exist only in practice. A covering physician answers questions during vacations but is not designated in the agreement.
9. A stale posting. The Rule 169.28 notice still names the previous physician after the PAA has been re-signed with a new one, or the reverse.
10. Re-delegation down the chain. An NP lets a medical assistant adjust doses or issue refills. The APRN cannot re-delegate what the physician delegated.

What happens next can be serious. Our delegation rules guide lists the monthly PAA meeting log among the four things auditors find missing first. Where prescribing turns out to rest on no valid authority, the exposure is not limited to the delegate: the physician who delegated remains responsible, and practising medicine without a licence is a third-degree felony in Texas under Occupations Code §165.152, with each day a separate offence.

How Do You Keep a Texas PAA Current?

Verdict: run the agreement on three clocks — a monthly QA meeting and chart review the statute requires, an annual dated and signed review the statute requires, and event triggers we recommend — and keep the evidence for each in one file.

What the PAA file should hold

Our delegation rules guide describes the per-provider file a Texas practice should be able to produce: the prescriptive authority agreement for each APRN and prescribing PA, with the annual review dated and signed, the QA plan, the monthly meeting log, the chart-review record, and a count confirming the physician is inside the seven-provider cap. Our Texas SOP manual guide adds that the APRN's or PA's role file should hold the current agreement with its annual review signature and, for a PA, evidence that the supervising physician's TMB registration is in force. Keep those together, in date order, and you can answer a document request in minutes rather than days.

Make the meeting log do the work

The monthly meeting is the clause most likely to drift because it depends on two busy clinicians finding time. The meeting need not be face to face — HB 278 removed that requirement in 2019 — but the record still has to exist. A one-page log per meeting is enough: the date, who attended, which patients or patterns were discussed, any change in care plans, any referral issue, and the follow-up owner. Have the physician sign or initial it. Twelve of those a year, plus the chart-review record and the annual signature, is the evidence that the QA plan is real.

Who owns the calendar

Name one person — usually the practice manager, sometimes the NP owner — as the owner of the PAA calendar. Their job is not clinical; it is to make sure the meeting is booked, the log is filed, the annual review happens before the anniversary date and every menu change goes past the agreement first. Our Texas SOP and policy manual guide shows where that responsibility sits alongside the rest of a Texas practice's delegation paperwork.

What Does Texas Not Require in a PAA?

Verdict: several numbers that circulate in vendor templates and online summaries do not appear in Texas law as our sources describe it — and importing them can make an agreement harder to comply with without making it more lawful.

• No chart-review percentage. The number of charts is set by the physician and the delegate. Choose one and evidence it.
• No quarterly step-down. The monthly meeting stays monthly; the older monthly-then-quarterly scheme was repealed by HB 278 in 2019.
• No face-to-face meeting rule. HB 278 removed it. The meeting still has to be documented.
• No distance or response-time standard for off-site oversight. For delegated cosmetic procedures, 22 TAC §169.26(d) requires a physician, PA or APRN to be on site or immediately available for emergency consultation, and our delegation guide notes the rule sets no distance or response time. That is a procedure-level rule, separate from the PAA, but agreements often try to restate it with invented numbers.
• No med spa licence that substitutes for the agreement. Texas has no med-spa-specific licence or registration; regulation follows the services, across the Texas Medical Board, TDLR, the Board of Nursing and DSHS.

For the state's full supervision and delegation profile with primary-source citations, see the Texas med spa regulations page. If a number in a template you are reviewing is not in that record or in the statute, ask your counsel where it came from before you sign it.

Should a Texas Med Spa Use a Template or a Lawyer?

Verdict: both, in that order. A template gets the structure right and saves billable hours; a Texas healthcare attorney confirms the agreement fits your physician, your delegates and your ownership structure.

Ownership is the reason the second step matters. Texas enforces the corporate practice of medicine doctrine, so the medical practice must be owned through a physician professional entity, commonly paired with a management services organization. A nurse practitioner can build and run a Texas med spa through that structure, practising inside the physician-owned clinical entity under their prescriptive authority agreement. In that arrangement the PAA is doing more than authorising prescriptions — it is one of the documents showing the physician's control is genuine. Our Texas nurse practitioner med spa playbook walks through that launch structure from the NP's side.

Use the template to arrive at counsel with a complete draft: statutory sections populated, the service schedule filled in, the QA plan numbered and the alternates named. Counsel's time then goes on judgment — controlled-substance language, termination mechanics, how the PAA interacts with the management services agreement — rather than on typing out the parties' addresses.

Frequently Asked Questions

Disclaimer: This article is for educational purposes only and does not constitute legal advice. Texas prescriptive authority, delegation and supervision rules are administered by more than one agency and can change. Confirm current requirements with the Texas Medical Board and the Texas Board of Nursing, and have a Texas healthcare attorney review any prescriptive authority agreement before it is signed.