Florida Supervising Physician Requirements and Ratios

Florida supervising physician requirements are set primarily by Sections 458.347, 458.348, 459.022, and 459.025 of the Florida Statutes, along with Board of Medicine rules in Chapter 64B8. In short: you must hold an active, unrestricted license in the specialty covering the delegated work, you can oversee no more than 10 physician assistants at once, you must file written notice of new and terminated supervisory relationships within 30 days, and you are personally liable for every act and omission of the PAs and APRNs working under you.

Who Can Serve as a Supervising Physician

Florida Administrative Code Rule 64B8-4.025 sets the baseline. The supervising physician must hold an active, unrestricted license under Chapter 458 (allopathic) or Chapter 459 (osteopathic), be in good standing, and be qualified by training and experience in the medical areas where the supervised provider will practice.¹ A dermatologist cannot supervise a PA doing orthopedic procedures. The physician’s own scope defines the outer edge of what can be delegated.

The rule also names specific disqualifiers. A physician who has been disciplined in any jurisdiction, who is currently under investigation, or who is not actively practicing in the relevant specialty area cannot serve as a supervisor.¹ For indirect supervision, the physician must practice within 20 miles of the supervised provider’s location. Direct supervision requires physical presence on the premises.

What Supervision Actually Means

Florida defines supervision of a PA as “responsible supervision and control.” Practically, that means the physician must be either physically present or easily reachable for consultation and available to direct the PA’s actions.² “Easy availability” explicitly includes telecommunication, so a phone or video call satisfies the standard outside of emergencies.³

Under Rule 64B8-30.012, the supervising physician decides whether a task requires direct or indirect supervision, and that decision has to be based on the risk of harm to the patient.⁴ Higher-risk procedures warrant tighter oversight. In a genuine emergency, a PA can act within their training to maintain life support until a physician takes over.

Supervision Ratios and Office Location Limits

A single physician cannot supervise more than 10 licensed physician assistants at any one time, under both Section 458.347 and Section 459.022.⁵³ That cap replaced an earlier limit of four.

Geography matters too. A physician providing primary care services cannot supervise more than four offices beyond their primary practice location. For specialty care, the cap drops to two additional offices.⁶ Physicians supervising PAs or APRNs at off-site locations where the primary services are dermatologic or aesthetic skin care face stricter rules, including board certification in dermatology or plastic surgery and submission of every supervised office address to the Board of Medicine.

Standing Orders, Delegated Tasks, and Chart Cosigning

A supervising physician can only delegate tasks and procedures that fall within their own scope of practice under Rule 64B8-30.012.⁴ A cardiologist cannot write standing orders authorizing a PA to perform procedures the cardiologist could not perform.

The physician must also be satisfied that the PA has the knowledge and skill to carry out each delegated task, and every task the PA performs must be documented in the patient’s medical record.⁴ Standing orders work best when they are built collaboratively and revisited as guidelines change.

One point catches physicians off guard. Florida law specifically says a supervising physician is not required to review and cosign charts or medical records prepared by a PA.² The flip side is that a physician cannot lean on a chart-review routine as proof of adequate supervision, because the law never required it. If a case goes bad, “I would have caught it in chart review” is not a defense.

Prescribing Authority You Delegate

Prescribing authority is delegated, not automatic. A supervising physician may authorize a fully licensed PA to prescribe or dispense medications used in the physician’s practice, but only after notifying the Department of Health on an approved form.² The PA must identify themselves as a physician assistant to every patient, and every prescription must include the PA’s name, address, phone number, and the name of the supervising physician.

The Joint Committee of the Boards of Medicine and Osteopathic Medicine maintains a negative formulary that prohibits PAs from prescribing general anesthetics, epidural anesthetics, and radiographic contrast materials in any form.⁷ Controlled substances have their own limits:

Schedule II prescriptions are limited to a 7-day supply.⁷
Schedule II psychiatric medications for minors are limited to a 14-day supply, and only when the supervising physician practices pediatrics, family practice, internal medicine, or psychiatry.

PAs with prescribing authority must also complete at least 10 hours of continuing education in their specialty area with each license renewal, with three of those hours devoted to safe and effective prescribing of controlled substances. Any PA prescribing controlled substances also needs a DEA registration, which requires state prescribing authority first.⁸

Notifying the Board Within 30 Days

When you enter into or terminate a supervisory relationship, standing orders, or protocol with an APRN, EMT, or paramedic, you must file written notice with the Board of Medicine within 30 days.⁶ Osteopathic physicians follow the same 30-day window under Section 459.025.⁹ The notice must identify the physician by name and license number, list the number and type of supervised providers, and state the effective date. The osteopathic board has clarified that no ongoing annual or biennial renewal notices are required; the initial filing and any termination filing are the only obligations.

Physicians supervising PAs or APRNs at offices other than their primary location must also report those addresses to the board. Missing a filing is treated as a basis for disciplinary action, not just a paperwork lapse.

How Autonomous APRN Practice Affects You

Florida’s 2020 House Bill 607 created a pathway for qualified APRNs to practice without physician supervision, but only in primary care (family medicine, general pediatrics, general internal medicine) and certified nurse midwifery.¹⁰ Certified registered nurse anesthetists and specialty nurse practitioners are not eligible.

For a supervising physician, the practical effect is that an APRN approaching 3,000 supervised clinical hours may be preparing to move to autonomous status. When that relationship ends, you have 30 days to file the termination notice.¹¹

Your Liability Exposure

Florida’s liability framework is direct. Section 458.347 states that each supervising physician is liable for any acts or omissions of a PA acting under the physician’s supervision and control.² Section 459.022 mirrors that language for osteopathic physicians.³ If a PA makes a clinical error, the supervising physician gets pulled into the malpractice claim whether or not they were physically present.

Board discipline is separate from civil liability. A physician who fails to comply with Section 458.348 faces disciplinary action that can include fines, license suspension, or revocation.⁶ Discipline is possible even when no patient was harmed; the supervisory failure itself is the violation.

Then there is the federal layer. If a malpractice payment is made on behalf of a supervising physician, even one named only because of a subordinate’s conduct, the insurer must report the payment to the National Practitioner Data Bank, with separate reports for each named practitioner.¹² An NPDB report follows a physician for the rest of their career and surfaces on every hospital and insurer query.

Medicare Billing and the Incident-To Supervision Standard

How a PA’s services get billed changes the supervision level you have to maintain. When a PA bills Medicare directly under their own NPI, the practice receives 85% of the physician fee schedule rate.¹³ Incident-to billing pays the full physician rate, but comes with conditions.

To qualify as incident-to, the physician must have personally performed the initial service for that patient and must remain actively involved in the course of treatment. The physician must also provide direct supervision, meaning immediate availability.¹⁴ CMS has permanently expanded “immediately available” to include real-time, two-way audio and video telecommunications; audio-only calls do not satisfy the requirement.

Two categories get a lighter touch. Chronic care management and transitional care management services billed incident-to require only general supervision, and behavioral health services provided by auxiliary personnel incident-to a physician’s services also fall under general supervision.¹⁴ Practices mixing billing approaches need to track which supervision standard applies to which service, because an audit finding direct supervision missing on an incident-to claim can trigger repayment demands and fraud scrutiny.

Staying Compliant Once the Relationship Is in Place

The physicians who run into trouble usually knew the rules on day one. They drifted. The PA’s volume grew, chart reviews tapered, standing orders went stale. By the time a complaint reaches the board, the gap between what was documented and what actually happened is wide enough to cost a license.

A few habits keep that from happening. Revisit standing orders at least annually and whenever specialty guidelines shift. Keep a log of supervisory interactions, including informal phone consultations, with date, clinical question, and guidance given. Give every PA and APRN a written scope of tasks tied to your own specialty qualifications. Treat the 30-day filing window as a hard deadline. And review your liability coverage every time the number or scope of supervised providers changes, because supervising ten PAs is not the same risk profile as supervising two, and finding out after a claim that coverage was inadequate compounds every other problem.

1
Cornell Law School. Florida Administrative Code Rule 64B8-4-025 – Licensure Under Supervision
2
Florida Senate. Florida Code 458-347 – Physician Assistants
3
Florida Legislature. Florida Code 459.022 – Physician Assistants
4
Cornell Law School. Florida Administrative Code Rule 64B8-30-012 – Physician Assistant Performance
5
Florida Senate. Florida Code 458.347 – Physician Assistants
6
Florida Legislature. Florida Code 458.348 – Supervisory Relationships and Protocols
7
Cornell Law School. Florida Administrative Code Rule 64B8-30-008 – Formulary
8
DEA Diversion Control Division. Registration Q&A
9
Florida Board of Osteopathic Medicine. Requirements for Physicians Reporting Supervisory Relationships
10
Florida Legislature. Florida Code 464.0123 – Autonomous Practice by an Advanced Practice Registered Nurse
11
Florida Board of Nursing. Advanced Practice Registered Nurse
12
U.S. Department of Health and Human Services. Reporting Medical Malpractice Payments
13
CMS. Physician Assistants (PAs)
14
CMS. Incident To Services and Supplies