TEXAS ~ STATUTE Continued

TEXAS ~ STATUTE STATUTE DATE Enacted 1981 REGULATORY BODY Texas Rev. Civ. Stat., Occupations Code, Chapter 204: Physician Assistant Licensing Act; Occupations Code Chapter 157; Authority of Physician to Delegate Certain Medical Acts Insurance Code 21.52, Section 1 Texas Physician Assistant Board; Texas Medical Board PA DEFINED Person licensed as PA under Chapter 204 157.051 SCOPE OF PRACTICE PRESCRIBING/DISPENSING SUPERVISION DEFINED PAs PER PHYSICIAN PA practice includes medical services within the education, training and experience of the PA that are delegated by the supervising physician. Includes but is not limited to histories and physicals, ordering or performing diagnostic and therapeutic procedures, formulating a working diagnosis, developing and implementing a treatment plan, monitoring effectiveness of therapeutic interventions, assisting at surgery, patient counseling and education, referrals. PA may perform delegated services in any place authorized by supervising physician including clinic, hospital, ambulatory surgical center, patient home, nursing home, or other institution. PA s signature attesting to provision of service PA is legally authorized to provide shall satisfy any documentation requirement established by state agency. PA is the agent of the PA s supervising physician for any medical services delegated by supervising physician. 204.202 A physician may delegate the administering, providing or carrying out a prescription drug order as authorized through standing medical orders, delegation orders, or other orders and protocols defined by the medical board at a site serving a medically underserved population (defined as a medically underserved area, health manpower shortage area, certified rural health clinic, state public health or family planning clinic, or other site designated by the health department) or at physician s primary practice site (a practice location where the physician spends the majority of time, a hospital or long term care facility where the PA is authorized to practice, an established patient s residence or any place where the physician is physically present with the PA), or at an alternate practice site which meets certain criteria. Protocols and other orders need not describe the exact steps that a PA must take with respect to each specific condition, disease or symptom and may state the types or categories of medications that may be prescribed or not prescribed. Carrying out a prescription drug order means to complete a Rx presigned by the delegating physician or the signing of a prescription by a PA designated by the physician as a delegated prescriber by providing the patient s name and address; drug to be dispensed; directions to patient; number of refills; name, address and phone of physician and PA; and PA identification number. Supervision adequate if the delegating physician is responsible for formulation or approval of standing orders and periodically reviews orders and services provided; is on-site at least once every 10 business days; receives daily status report from PA on any problems or complications; and is available through direct telecommunication for consultation, referral or emergencies. Physicians in public health clinics may delegate to PA the acts of administering or providing dangerous drugs. Providing means to supply 1 or more doses in properly labeled suitable container. 157.002-.057 PA may request, receive, and sign for pharmaceutical samples and distribute samples in setting where PA authorized to prescribe. 204.202 Supervision must be continuous but does not require constant physical presence of supervising physician where PA services are being performed. When physician not present PA and physician must be able to be in contact with one another by radio, telephone, or other telecommunication device. 204.204 Physician/PA team must ensure that relationship between team members and access of PA to supervising physician is defined and process for evaluating PA s performance is established. 204.206 Physician may delegate prescriptive authority to PA practicing in medically underserved area if physician is on-site to provide medical direction and consultation at least once every 10 business days during which PA is on-site providing care. 157.052 Physician s authority to delegate the carrying out or signing of a prescription at his primary practice site is limited to 3 PAs or their FTE. 157.054 APPLICATION PA applies for license on board forms. 204.152 Licensed PA must file notification of intent to practice on board forms prior to beginning practice. Form must include name, address, license number and phone number of supervising physician. 204.201 Physician must receive approval from medical board to supervise PA. 204.205

TEXAS ~ STATUTE Continued QUALIFICATIONS Successful completion of PA program accredited by CAHEA, its predecessor or successor Passage of PANCE exam given by NCCPA and current NCCPA certification Good moral character Meet any other board requirements Passage of jurisprudence exam 204.153 TEMPORARY PERMIT TERMINATION Board may issue temporary license to applicant who meets all qualifications but is waiting for meeting of board for the license to be issued; seeks to substitute for a licensed PA during licensed PA s temporary absence if applicant is licensed in another jurisdiction; has graduated from accredited PA program no later than 6 months previous to application and is waiting for exam results from the NCCPA. Temporary license may be valid for not more than 1 year from date issued. 204.155 PA must notify board of any changes in or additions or deletions of supervising physicians not later than the 30th day after change is made. 204.201 CONTINUING EDUCATION Board to establish requirements by rule. 204.1562 TITLE/PRACTICE PROTECTION IDENTIFICATION PHYSICIAN LIABILITY Person not holding license as a PA who holds himself out as a PA, uses PA title or acts as a PA is guilty of a third degree felony. 204.352 Licensed PA shall keep license available for inspection at primary place of business and wear a name tag identifying PA as a physician assistant when engaged in professional activities. 204.203 Legal responsibility for PA s patient care activities remains responsibility of the supervising physician including when PA provides care and treatment of a patient in a facility. If PA employed by entity, including facility, entity shares legal responsibility for PA s acts or omissions with supervising physician. 204.207 FEE/RENEWAL SCHEDULE PA board establishes and collects reasonable fees 204.103 Licensed PA may renew license on notification from board by paying prescribed fee, submitting board form and meeting any other board requirements. 204.156 PROGRAM APPROVAL No provision (statute recognizes accreditation by CAHEA or successor or predecessor agency) BOARD REPRESENTATION/ ADVISORY COMMITTEE BOARD POWERS DISCIPLINARY POWERS Texas Physician Assistant Board is created as an advisory board to medical board. Consists of 9 governor-appointed members (advice and consent of Senate required): 3 currently practicing PAs with at least 5 years of clinical experience, 3 physicians who supervise PAs, and 3 public members. Governor selects a presiding officer; board selects a secretary from among its membership. 204.051 The PA board shall adopt rules, review and approve, reject or issue licenses and license renewals, prescribe and collect fees. 204.101 Act on complaints 204.108 Medical board approves or rejects rules adopted by PA board. Approved rules take effect; rejected rules returned to PA board for revision. 204.102 Board may refuse to issue license, publicly or privately reprimand licensee, suspend, revoke, restrict license, require PA to submit to care or counseling of designated practitioner, stay enforcement and place on probation, impose remedial measures or sanctions, order PA to perform public service or complete additional training, impose an administrative penalty, administer a public reprimand, or impose non-disciplinary rehabilitation order. 204.252,305, 306 Board may delegate to the medical board employees or committee authority to dismiss or enter into agreed settlement on complaint. 204.3011 VIOLATIONS/PENALTY Fraud in obtaining or using license Representing oneself as physician Conduct likely to deceive, defraud, or injure public Aiding or abetting unlicensed practice False or deceptive advertising Violating chapter or rule Felony conviction or violation of law connected with PA practice Violation of drug record laws False prescribing Habitual use of drugs or alcohol to extent that safe practice impaired

TEXAS ~ STATUTE Continued Adjudication of mental incompetence Mental or physical condition that impairs safe practice Commission of an act of moral turpitude Failure to practice in acceptable manner Discipline by another jurisdiction Nontherapeutic prescribing Disciplinary action by professional association or health care facility Professional incompetence Sexual abuse or exploitation of person through PA license Violation of rehabilitation order 204.302-306 PAYMENT FOR SERVICES PAs are listed in insurance code; health insurance policy may not discriminate in payment schedule or payment provisions for services provided by PA if same services covered when performed by any other practitioner of the healing arts whose services are covered by the policy. Policy may provide for a different amount of payment or reimbursement for scheduled services when performed by PA provided reimbursement methodology used to calculate payment is the same methodology used to calculate payment when service is provided by a physician. 21.25, Sec. 1 GRANDFATHER CLAUSE No provision STUDENTS Students enrolled in accredited PA programs do not require a license. 11 LOCUM TENENS [See Temporary Permit] OTHER Nothing in this chapter limits the employment arrangement of licensed PA 204.003

TEXAS ~ REGULATIONS REGULATIONS Rules for Physician Assistants Chapter 185; Standing Delegation Orders Chapter 193; Supervision of PA Students Chapter 162; Fees Chapter 175 DATE Revised 6/06 REGULATORY BODY Texas Physician Assistant Board; Texas Medical Board PA DEFINED Person licensed as PA by the board. 185.2 SCOPE OF PRACTICE PA may provide medical services within education, training and experience of PA delegated by supervising physician. May be performed in any place authorized by supervising physician, including but not limited to clinic, hospital, ambulatory surgical center, patient home, nursing home or other institutional setting. Services may include but are not limited to histories and physicals, ordering or performing diagnostic and therapeutic procedures, formulating a working diagnosis, developing and implementing a treatment plan, monitoring effectiveness of therapeutic interventions, assisting at surgery, patient counseling and education, referrals. 185.11 PA may not maintain an office practice setting separate from that of supervising physician except at site serving medically underserved populations. 185.16 PRESCRIBING/DISPENSING SUPERVISION DEFINED PAs PER PHYSICIAN A physician may authorize a PA to complete and issue prescriptions for medications when treating patients at a site serving a medically underserved population or at physician s primary practice site or alternate site (physician must be present 20% of the time; additional stipulations apply) or at a hospital or long term care facility. Delegated prescribing may include legend drugs and Schedule III-V controlled medications. Controlled substance prescriptions limited to 30 days; refill must be authorized after consultation with supervising physician. Prescription for controlled medications for child under 2 years of age requires consultation with supervising physician. 193.6 PA may request, receive and sign for the receipt of pharmaceutical samples and distribute the samples in settings where PA is authorized to prescribe. 185.11 Overseeing the activities of and accepting responsibility for services rendered by a PA. Does not require the constant physical presence of supervising physician but supervising physician and PA must easily be in contact via telephone or other telecommunication device. 185.2 Supervision shall be continuous, but shall not be construed as necessarily requiring constant physical presence of supervising physician. Physician/PA team must ensure that access to supervising physician is defined. PAs must utilize standing delegation orders, standing medical orders, protocols, or practice guidelines. 185.14 Except at site serving medically underserved, PA may not practice at site where PA s supervising physician is not present at least 20% of the time the clinic is open unless supervising physician has obtained a waiver from the board. 185.16 Physician supervision of a PA at a site serving a medically underserved population adequate if the physician: receives daily status report on problems not covered by a protocol visits the clinic at least once every 10 business days is available by telephone or direct telecommunication at all times clinic is open verifies that care is in accordance with quality assurance plan on file at the clinic which includes a random review and countersignature of at least 10% of patient charts. A physician may not supervise more than 3 clinics or any number of clinics with combined business hours exceeding 150 hours per week without board approval. Supervision of prescribing to conform to what a reasonable, prudent physician would find consistent with sound medical judgment; may vary with education and experience of PA. Supervision must be documented (summary requirements detailed). Board may grant waivers of supervision requirements if compliance would cause undue burden without corresponding benefit to patient care. 193.6 Supervising physician may supervise up to 5 PAs or their FTEs. Physician who provides medical services in preventive medicine, disease management, health and wellness education, or similar services in accredited teaching institution (institutions listed in rules) may supervise more than 5 PAs provided supervising physician determines that PAs are properly trained to deliver services, that services are of such nature that they may be delivered by PA and proper paperwork is filed with medical board.

TEXAS REGULATIONS Continued A physician holding the position of medical director, chief of staff, or emergency room department chair at a licensed hospital may supervise more than 5 PAs in order to staff an emergency department. Supervising physician must determine that PAs are properly trained to deliver services, that services are of such nature that they may be delivered by PA, and that proper paperwork is filed with the Medical Board. 185.16 Physician s authority to delegate prescribing at primary practice site, alternate practice site and long term care facility is limited to 3 PAs or their FTE. 193.6 APPLICATION PA applies for license on board forms. 185.4 Licensed PA must submit notification of intent to practice prior to practicing as a PA. Notification must include name, address, license number and phone numbers of PA and supervising physician. 185.13 QUALIFICATIONS TEMPORARY PERMIT TERMINATION Successful completion of PA program accredited by CAHEA, its predecessor or successor Current NCCPA certification (After September 1, 2007, must have passed the NCCPA exam within 6 attempts) Ability to mentally and physically function as a PA Good moral character No disciplinary action in another jurisdiction Any additional information requested, including malpractice claims After September 1, 2007, must pass (within 3 attempts) a jurisprudence exam covering laws and regulations applicable to PA practice in Texas. Applicant who has not been a student or who has not been in full time practice as a PA in the preceding 2 years must meet any requirements which the board deems necessary. 185.4 Board may issue temporary license to applicant in the following circumstances: PA meets all qualifications for licensure but is waiting for next meeting of board; PA seeks to substitute for a licensed PA during PA s temporary absence if applicant is licensed in another jurisdiction; P has graduated from accredited PA program no later than 6 months previous to application and is waiting for exam results from the NCCPA; PA meets the requirements for licensure, but has not worked full-time in 2 years. Board to determine requirements and duration of temporary license. PA may apply for license upon meeting board s requirements. Temporary license is valid for not more than one year from the date issued. 185.7 PA must notify board of any changes or additions in supervising physicians not later than 30th day after date the change is made. 185.13 CONTINUING EDUCATION 40 hours of CME required for annual license renewal. At least one-half must be Category I. Board may grant exemption for cause. 185.6 TITLE/PRACTICE PROTECTION IDENTIFICATION PHYSICIAN LIABILITY FEE/RENEWAL SCHEDULE PROGRAM APPROVAL BOARD REPRESENTATION/ ADVISORY COMMITTEE BOARD POWERS Except as otherwise provided, individual shall be licensed by the board before the individual may function as a PA. 185.4 Licensed PAs shall keep license available for inspection at primary place of business and wear a name tag identifying PA as a physician assistant. 185.12 Supervising physician is a doctor of medicine or osteopathic medicine who assumes responsibility and legal liability for services rendered by the PA. 185.2 $205 processing fee for license application $160 annual license renewal $50 temporary license 175 No provision [See statute] [See statute]

TEXAS REGULATIONS Continued DISCIPLINARY POWERS Board may impose discipline as authorized by statute 185.18 VIOLATIONS/PENALTY PAYMENT FOR SERVICES GRANDFATHER CLAUSE STUDENTS LOCUM TENENS Board may impose an administrative penalty; fine for each violation not to exceed $5,000 185.19 Fraudulently obtains or attempts to obtain a license Fraudulently or deceptively uses a license Fraud or felony conviction Violation of statute or rules Commission of an act of moral turpitude; misrepresentation Use of drugs or alcohol to extent that PA cannot safely practice Adjudication as mentally incompetent or mental or physical condition that renders PA unable to practice safely Representation of oneself as physician Unprofessional or dishonorable conduct; professional incompetence Failure to practice in an acceptable or safe manner Violation of state law if violation connected with PA practice Sanction against PA license in another jurisdiction Failure to keep records of purchase and disposal of drugs Writing false or fictitious prescription Prescribing, dispensing, or administering a non-therapeutic drug or treatment False advertising Aiding PA practice by a person not licensed as a PA Disciplinary action taken by professional association or licensed facility Repeated malpractice claims that evidence professional incompetence Sexual abuse or exploitation 185.17 PA may not independently bill patients for services except when provided by law. 185.16 No provision Physician who precepts PA student must have active unrestricted Texas medical license, must retain responsibility for care rendered by student and must, unless supervising students at program site, have a valid written agreement with program that authorizes physician to supervise students. Agreement must be made available to board upon request. 162.2 [See Temporary Permit] OTHER