Texas Physical Therapy Practice Act: Licensing and Direct Access

The Texas Physical Therapy Practice Act, codified as Chapter 453 of the Texas Occupations Code, is the state law that decides who can practice physical therapy in Texas, what they are allowed to do, and how they can lose the right to do it. It created the Texas Board of Physical Therapy Examiners and gives that board authority over licensure, standards of care, and discipline.¹ If you treat patients in Texas as a physical therapist or physical therapist assistant, every rule below applies to you.

What Counts as Physical Therapy Practice

Section 453.001 defines physical therapy as “a form of health care that prevents, identifies, corrects, or alleviates acute or prolonged movement dysfunction or pain of anatomic or physiologic origin.”² Section 453.005 fleshes that out: testing the function of the musculoskeletal, neurological, pulmonary, and cardiovascular systems, and rehabilitative treatment to restore function or prevent disability from illness, injury, or birth defect. Consultation, patient education, and delegation to support staff also fall inside the scope, though the licensed therapist remains responsible for the care.³

The Act also draws hard limits. Under Section 453.303, a physical therapist cannot use X-rays or radium to diagnose or treat, and cannot use electricity for surgical purposes such as cauterization.⁴ Surgery and independent diagnosis of disease belong to the medical practice act, not to physical therapy. Practicing across those lines is grounds for discipline.

Qualifying for a Texas License

You cannot treat a single patient in Texas without a license from the Texas Board of Physical Therapy Examiners. The pathway has three parts: education, examination, and a background check.

You must graduate from a program accredited by the Commission on Accreditation in Physical Therapy Education, pass the National Physical Therapy Examination, and pass the Texas Jurisprudence Exam on state-specific laws and board rules.² Every applicant also submits fingerprints through IdentoGO for state and federal criminal history checks reviewed by the Texas Department of Public Safety and the FBI.⁵ Submitting false educational credentials can result in permanent denial.

Practicing in Texas Under the Compact

Texas joined the Physical Therapy Licensure Compact in 2017 through Senate Bill 317, and compact privileges became available on January 2, 2019.⁶ If you hold a license in another compact state, you can practice in Texas under a compact privilege rather than obtaining a second full license.

To activate the privilege you must pass the Texas Jurisprudence Assessment Module and complete a Compact Privilege Practice Location form. The fees are a $45 national PT Compact Commission fee and a $50 Texas fee.⁶ Texas-licensed therapists heading to another compact state apply through that state’s rules.

Treating Patients Without a Physician Referral

House Bill 29, passed by the 86th Legislature, opened direct access in Texas, but only for therapists who meet specific qualifications. You must have been licensed for at least one year, carry professional liability insurance at the board-required minimum, and meet one of two education thresholds: a doctoral degree in physical therapy from an accredited program, or at least 30 hours of continuing competence activities specifically in differential diagnosis.⁷ Generic continuing education hours do not count.

The board set the minimum liability coverage at $100,000 per claim and $300,000 per year.⁸

How Long You Can Treat Without a Referral

A qualifying therapist can treat a patient without a referral for up to 10 consecutive business days. That window extends to 15 consecutive business days if the therapist holds a doctoral degree and has also completed a residency, fellowship, or board-approved certification.⁷ After that, a referral from a referring practitioner is required to continue treating. Continuing beyond the window without a referral violates the Practice Act.

The Required Disclosure Form

Before treating without a referral, the therapist must have the patient sign a board-prescribed disclosure form acknowledging four points: that physical therapy is not a substitute for a medical diagnosis by a physician; that it is not based on radiological imaging; that a physical therapist cannot diagnose an illness or disease; and that the patient’s health insurance may not cover the services.⁷ The signed form goes into the patient’s clinical record. Missing any of the four acknowledgments creates an audit exposure.

Medicare Patients Are a Separate Issue

State direct access does not override Medicare’s rules. A Medicare beneficiary can see a physical therapist without a physician visit, but a physician or non-physician practitioner must certify the plan of care with a dated signature within 30 calendar days of the first treatment session.⁹ Starting in 2025, if the physician has not signed and returned the plan of care within 30 days, a signed written order or referral can substitute for the plan-of-care signature.

Supervising Assistants and Aides

The licensed physical therapist carries ultimate legal responsibility for every patient, including anything delegated. The rules for assistants and aides are not the same.

Physical Therapist Assistants

A physical therapist assistant works under the direction of a licensed PT and can carry out treatments outlined in the plan of care. The supervising therapist does not need to be in the same room or building but must remain available by telecommunication at all times while the PTA is providing services, and must periodically re-evaluate the patient to confirm the plan of care remains appropriate. In 2025, CMS aligned Medicare supervision of PTAs in private practice with all other Medicare settings, shifting from direct supervision to general supervision.

Aides

Aides face tighter rules. A PT or PTA must provide on-site supervision and stay within reasonable proximity during any patient interaction. Aides cannot perform evaluations or assessments, cannot initiate treatment (including exercise instruction), and cannot write or sign entries in the permanent record, though they may enter quantitative data for delegated tasks. Telehealth cannot be used to supervise aides.¹⁰

Improper delegation puts the supervising therapist’s license at risk. The Act authorizes administrative penalties of up to $200 per violation, with each day of continued violation counting as a separate offense.⁴

Telehealth Rules

Board rules authorize physical therapy by telehealth, defined as the use of telecommunications or information technology to treat a patient physically located in Texas while the therapist is elsewhere. The therapist must hold an unrestricted Texas license or a compact privilege to practice in Texas.¹⁰

Sessions must be synchronous audiovisual or audio contact between therapist and patient. Store-and-forward technology can supplement live sessions but cannot replace them. The standard of care matches in-person treatment, and the therapist decides whether a given evaluation or intervention can be done remotely.¹⁰ Informed consent must be obtained before telehealth begins, and sessions must comply with HIPAA and other privacy laws. Failing to follow these rules is detrimental practice and can trigger discipline.

Renewing Your License

Texas physical therapy licenses expire every two years. Physical therapists must complete 30 Continuing Competence Units in each renewal cycle; physical therapist assistants must complete 20.¹¹ The activities must be completed within the two years before expiration and approved by the Texas Physical Therapy Association before renewal is submitted.

Practitioners providing direct patient care must also complete an approved human trafficking prevention training course as part of those units, a requirement rooted in Texas Occupations Code Chapter 116.¹² A jurisprudence assessment is required each renewal period. Keep documentation of your continuing competence activities for four years after the license expiration date in case of audit; keeping records only through the renewal period itself is a common mistake.¹³

Late and Expired Licenses

Missing the renewal deadline triggers late fees. If the license has been expired fewer than 90 days, the late fee is half the renewal fee. Between 90 days and one year, the late fee equals the full renewal fee.¹⁴ Once a license has been expired for a year or more, it cannot be renewed at all; the licensee must go through the longer license restoration process.

Practicing on an expired license is not just paperwork. Under Section 453.455, knowingly violating any provision of Chapter 453, including the requirement to hold a valid license, is a Class A misdemeanor, and each day counts as a separate offense.¹⁵

Grounds for Discipline

Section 453.351 gives the board broad authority to deny, suspend, or revoke a license, order probation, issue a reprimand, or impose administrative penalties. The grounds include:

Providing care beyond what Chapter 453 authorizes, except under the direct access provisions of Section 453.302.
Using drugs or alcohol to a degree that impairs professional competence.
Any felony conviction, guilty plea, or nolo contendere plea in Texas or another jurisdiction.
Attempting to secure licensure through fraud or deception.
Providing care so far below the standard of competence that it constitutes gross negligence.
Practicing in a manner harmful to the public health and welfare.
Having a license refused, revoked, or suspended in another state.
A physical therapist assistant who treats patients without the direction of a licensed physical therapist.¹⁶

A finding on any of these can end a career, and the daily-offense structure in the Act means violations rarely stay small once they start.

1
Executive Council of Physical Therapy and Occupational Therapy Examiners. PT – Act and Rules
2
State of Texas. Texas Occupations Code Section 453.001 – Definitions
3
State of Texas. Texas Occupations Code Section 453.005 – Practice of Physical Therapy
4
State of Texas. Texas Occupations Code Chapter 453 – Physical Therapists
5
Texas Board of Physical Therapy Examiners. Procedures for Fingerprints
6
Executive Council of Physical Therapy and Occupational Therapy Examiners. Compact
7
Texas Legislature Online. HB 29 – 86R
8
Executive Council of Physical Therapy and Occupational Therapy Examiners. How Much Professional Liability Insurance Must a PT Carry in Order to Treat Patients Without a Referral
9
Centers for Medicare & Medicaid Services. Complying with Outpatient Rehabilitation Therapy Documentation Requirements
10
Cornell Law Institute. 22 Texas Admin Code 322.5 – Telehealth
11
Executive Council of Physical Therapy and Occupational Therapy Examiners. Continuing Competence and License Renewal
12
Texas Department of Licensing and Regulation. Human Trafficking Prevention Training for Health Care Practitioners
13
Texas Board of Physical Therapy Examiners. Texas Board of Physical Therapy Examiners Rules – Section 341.2
14
Executive Council of Physical Therapy and Occupational Therapy Examiners. Renew an Expired (Late) License
15
Justia. Texas Occupations Code Chapter 453 – Physical Therapists
16
Texas Board of Physical Therapy Examiners. Texas PT Practice Act