Texas Occupations Code Chapter 157 sets the rules for when a licensed Texas physician may hand off clinical tasks — from administering a drug in the office to writing prescriptions — to other healthcare professionals. Subchapter A covers delegation of medical acts generally. Subchapter B covers the written prescriptive authority agreements that let physician assistants and advanced practice registered nurses prescribe. The Texas Medical Board enforces both, and a physician who gets the delegation wrong can face discipline against their license.
What a Physician May Delegate
Section 157.001 sets the baseline. A physician may delegate any medical act to a qualified and properly trained person if a reasonable and prudent physician would find the delegation within sound medical judgment. Three conditions travel with that authority. The delegate must be able to perform the act properly and safely. The act must be performed in its customary manner. And the delegation cannot violate any other statute.1Texas Public Law. Texas Occupations Code Section 157.001 – General Authority of Physician to Delegate
The delegate cannot hold themselves out to the public as authorized to practice medicine independently. The delegating physician remains legally responsible for what the delegate does, and the Texas Medical Board keeps the authority to decide whether a given act is the practice of medicine and whether it can safely be delegated at all.1Texas Public Law. Texas Occupations Code Section 157.001 – General Authority of Physician to Delegate
This is where most delegation trouble starts. The judgment call sits with the physician, not the delegate. Handing off a task to someone without the training to do it exposes the physician even if the delegate agreed to try.
Delegating Drug Administration in the Office
Section 157.002 covers a narrower question: having staff administer or provide dangerous drugs. A physician may delegate the administration of a dangerous drug — by injection, inhalation, ingestion, or another method — or the provision of unit doses to a qualified, properly trained person working under the physician’s supervision. The drugs have to be used for the immediate needs of the physician’s patients, and everything has to comply with state and federal drug laws.
Setting matters. In the physician’s office, the delegate acts on the physician’s orders. Through a facility licensed by the Texas State Board of Pharmacy, the same delegation is available, but pharmacist licensing rules layer on.
Section 157.002 also names the vehicles that carry the delegation: a direct physician’s order, a standing medical order, a standing delegation order, or another order type defined by the board. Standing delegation orders are written protocols that let staff start a specific treatment or administer a medication without waiting for a fresh order each time. They have to be clear enough that staff can follow them exactly as the physician intended.
Prescriptive Authority Agreements for PAs and APRNs
Subchapter B builds a separate framework for physician assistants and advanced practice registered nurses who need to prescribe rather than just administer. A prescriptive authority agreement is the formal written arrangement between the physician and the delegate. It sets out which drugs the delegate may prescribe, where they may practice, and how the physician will oversee their prescribing.
Section 157.0512 lists the minimum contents. Among them, the agreement must describe a prescriptive authority quality assurance and improvement plan with two elements: chart reviews, with the physician and delegate deciding how many charts to review, and periodic meetings between the two.2State of Texas. Texas Occupations Code Section 157.0512
Those meetings must happen at least once a month, in whatever manner the physician and delegate agree on. They must cover patient treatment and care, changes needed to care plans, referral issues, and discussion of patient care improvement. Every meeting must be documented. If the arrangement uses alternate physician supervision, the agreement must designate one or more alternate physicians who can supervise temporarily and take part in the quality assurance meetings.2State of Texas. Texas Occupations Code Section 157.0512
The agreement and any amendments must be available to the Texas Medical Board, the Texas Board of Nursing, or the Texas Physician Assistant Board on request. Physicians must produce the agreement within three business days of a board request. Missing that window can bring discipline.3Texas Medical Board. Prescribing and Supervision
The 1:7 Ratio and Board Registration
Texas caps how many delegates a single physician can supervise for prescriptive authority. In most practice settings, one physician may delegate to no more than seven full-time-equivalent APRNs and PAs — commonly called the 1:7 ratio.4Texas Medical Board. Is There Still a Ratio for the Number of APRNs or PAs to Whom a Physician May Delegate Prescriptive Authority Part-time delegates count as partial FTEs, so a physician working with several part-time PAs can supervise more than seven people as long as the combined FTE count stays at or below seven.
Registration comes before practice. Physicians must register their prescriptive authority delegations with the Texas Medical Board before the delegate starts working. The TMB uses an online system, and hard-copy forms are generally no longer accepted. Any change to supervision or the scope of delegation has to be updated in the system within 30 days. The board has said plainly that a late update does not retroactively fix liability for the period when the registration was inaccurate.3Texas Medical Board. Prescribing and Supervision
PAs carry their own registration duty. They must register their supervising physicians with the board before beginning to practice under the agreement and report any change within 30 days.3Texas Medical Board. Prescribing and Supervision
Controlled Substances Add Another Layer
Prescriptive authority for controlled substances comes with extra restrictions. The agreement itself must spell out which schedules the delegate may prescribe. For physician assistants, Texas currently limits Schedule II prescribing to hospice and inpatient care settings. Schedules III through V are more broadly available but still need explicit authorization in the agreement.
Federal law adds a second layer. Every mid-level practitioner who prescribes controlled substances must hold their own DEA registration, separate from the supervising physician’s. The DEA defines a mid-level practitioner as an individual practitioner (other than a physician, dentist, veterinarian, or podiatrist) who is licensed to dispense controlled substances. The employee exemption that lets some staff work under a physician’s DEA registration does not extend to prescribing controlled substances and does not apply to mid-level practitioners at all.5Drug Enforcement Administration. Practitioner’s Manual
To register, the practitioner needs a valid state license and completes DEA Form 224 online. A separate registration is required for each principal place of business where controlled substances are dispensed. The DEA leans on state licensing boards to set which schedules a practitioner may handle, and that state authority only reaches inside the issuing state’s borders.5Drug Enforcement Administration. Practitioner’s Manual
The 48-Hour Obstetrical Carve-Out
Section 157.059 addresses delegation in obstetrical services specifically. It allows a physician to authorize the provision of certain drugs or devices related to obstetrical care for a period not exceeding 48 hours. It is a narrower window than the general framework and reflects the time-sensitive situations obstetrics can present when the physician is not immediately present.
When the Physician Is Still on the Hook
Section 157.060 gives physicians a limited liability shield. A physician is not liable for the act of a PA or APRN solely because the physician signed a standing medical order, standing delegation order, or prescriptive authority agreement authorizing the delegate to administer, provide, prescribe, or order a drug or device.6State of Texas. Texas Occupations Code Section 157.060 – Physician Liability for Delegated Act
The shield has a critical exception. It does not apply if the physician had reason to believe the delegate lacked the competency to perform the act. A physician who knows or should know that a delegate is struggling with a particular clinical decision cannot rely on the agreement when something goes wrong. The statute rewards diligent oversight and punishes willful blindness.6State of Texas. Texas Occupations Code Section 157.060 – Physician Liability for Delegated Act
Ordinary vicarious liability still applies alongside §157.060. Under respondeat superior, an employer answers for the negligent acts of employees acting within the scope of employment, no matter how careful the supervision was. So a physician who employs the delegate can be liable for the delegate’s clinical errors even when the physician’s own oversight was reasonable. If the delegate is an independent contractor, respondeat superior does not apply, but the physician can still face liability under an ostensible agency theory when patients reasonably believed the delegate was the physician’s employee.
Medicare Incident-To Billing Sits on Top
When delegated services get billed to Medicare, federal rules add to the Texas requirements rather than replace them. The incident-to provision at 42 CFR § 410.26 lets services performed by auxiliary personnel be billed under the supervising physician’s name, but only if the service is an integral part of the physician’s diagnosis or treatment, the type of service commonly furnished in a physician’s office, and provided in a noninstitutional setting.7eCFR. 42 CFR 410.26 – Services and Supplies Incident to a Physician’s Professional Services
The default supervision standard is direct supervision: the physician must be present in the office suite while the delegate performs the service. CMS has expanded “present” to include virtual presence through real-time audio and video for services without a surgical global period indicator. Certain care management and behavioral health services qualify for a lower general supervision standard, which does not require the physician to be present at all.7eCFR. 42 CFR 410.26 – Services and Supplies Incident to a Physician’s Professional Services
Only the supervising physician may bill Medicare for incident-to services. The auxiliary personnel can be an employee, leased employee, or independent contractor, but they cannot be excluded from Medicare or Medicaid, cannot have had Medicare enrollment revoked, and must meet all applicable Texas licensure requirements.7eCFR. 42 CFR 410.26 – Services and Supplies Incident to a Physician’s Professional Services
When a delegate documents the encounter, CMS requires the supervising physician to authenticate the record. A signature signifies knowledge, approval, acceptance, or obligation regarding the documented care. If a scribe or AI tool creates the entry, the physician still has to sign to authenticate it, though there is no requirement to identify who or what transcribed the note.8Centers for Medicare & Medicaid Services. Complying with Medicare Signature Requirements
Billing Medicare or Medicaid for delegated services that do not actually meet the supervision requirements creates exposure under the False Claims Act. The Act reaches claims a physician knows or should know are false, and a service not provided under proper supervision can be treated as a service “not provided as claimed.” The knowledge standard covers actual knowledge, deliberate ignorance, and reckless disregard; no specific intent to defraud is required.9Office of Inspector General. Fraud and Abuse Laws Each individual service billed counts as a separate claim, and civil penalties currently run from $14,308 to $28,619 per false claim, plus up to three times the government’s loss.10Sidley Austin LLP. Department of Justice Announces 2025 Inflationary Adjustments to FCA Penalties
The Office of Inspector General can also pursue exclusion from all federal healthcare programs, including Medicare, Medicaid, TRICARE, and the Veterans Health Administration. An excluded physician cannot bill these programs directly, and no employer or group practice can bill for the excluded physician’s services indirectly.9Office of Inspector General. Fraud and Abuse Laws For a practice built around federal payers, exclusion often hurts more than the financial penalties.