What a practice agreement with a physician covers

What the agreement is

Virginia requires the arrangement in a single sentence and then spends several subsections describing it.

Every nurse practitioner who does not meet the statutory requirements for autonomous practice shall maintain appropriate collaboration and consultation, as evidenced in a written or electronic practice agreement, with at least one patient care team physician.

The Boards of Medicine and Nursing jointly promulgate regulations specifying that collaboration and consultation, and the statute tells them what those regulations must include: the development of, and periodic review and revision of, a written or electronic practice agreement; guidelines for availability and ongoing communications that define consultation among the collaborating parties and the patient; and periodic joint evaluation of the services delivered.

The agreement itself must contain provisions for periodic review of health records, which may include visits to the site where health care is delivered, in the manner and at the frequency determined by the nurse and the patient care team physician, and provisions for input from appropriate health care providers in complex clinical cases and patient emergencies, and for referrals.

Evidence of a practice agreement shall be maintained by the advanced practice registered nurse and provided to the boards upon request. For a nurse working within a hospital or health care system, the agreement may be included as part of the documents delineating clinical privileges or the written or electronic delineation of duties and responsibilities.

The physician assistant version

Virginia builds the same idea around a named structure it calls a patient care team.

A patient care team physician or podiatrist may serve on a patient care team with physician assistants and shall provide collaboration and consultation to them, and shall be available at all times to collaborate and consult, except with assistants authorised to practise without a practice agreement.

The team has to define its own terms. Each patient care team shall identify the relevant physician assistant's scope of practice and an evaluation process for the assistant's performance.

The statute also bounds who can be responsible for whom. No person shall have responsibility for any physician assistant who is not employed by the person or the person's business entity.

One clause limits what serving on the team means legally. Service as part of a patient care team by a patient care team physician or podiatrist shall not, by the existence of such service alone, establish or create vicarious liability for the actions or inactions of other team members, and the nursing section carries an equivalent sentence.

What the agreement has to say about prescribing

The prescribing provisions are where a practice agreement stops being a general statement of collaboration and becomes a specific document.

For a physician assistant, the practice agreement or arrangement, if necessary, shall include a statement of the controlled substances the assistant is or is not authorised to prescribe, and may restrict that prescriptive authority as deemed appropriate by the patient care team physician or podiatrist.

The statute then makes departure from it unlawful. It is unlawful for the physician assistant to prescribe controlled substances or devices unless the prescription is authorised by the requirements of the section and by the practice agreement, by the credentialing and privileging arrangement of a named category of facility, or in accordance with an authorisation to practise without an agreement.

The nursing version is stricter about evidence. A nurse who does not meet the autonomous practice requirements shall prescribe controlled substances or devices only if authorised by a written or electronic practice agreement, and shall provide the boards with such evidence as they jointly require that they are, at the time of writing a prescription, a party to an agreement that clearly states their prescriptive practices.

The document must also be attributable. Practice agreements authorising a nurse to prescribe shall either be signed by the patient care team physician or shall clearly state the name of the physician who has entered into the agreement.

How many, and for how long

Virginia caps the arrangement in both directions, and the two ceilings are different numbers in different sections.

For physician assistants, no patient care team physician or podiatrist shall be allowed to collaborate or consult with more than six physician assistants on a patient care team at any one time.

For advanced practice registered nurses, physicians shall not serve as a patient care team physician on a patient care team or enter into a practice agreement with more than six at any one time, except that a physician may serve on a team with up to ten nurses licensed in the psychiatric-mental health category.

The requirement is also time-limited for nurse practitioners who accumulate experience. A nurse practitioner who has completed the equivalent of at least three years of full-time clinical experience, as determined by the boards, may practise in the category in which they are certified and licensed without a written or electronic practice agreement, on receipt of an attestation from the patient care team physician or a qualifying attesting nurse practitioner.

That attestation has to state specific things: that the attesting party served on a patient care team with the nurse practitioner under a qualifying practice agreement; that while a party to it, the attesting party routinely practised with a patient population and in a practice area included within the category for which the nurse practitioner was certified and licensed; and the period of time for which they practised together under such an agreement. On verification, the boards issue a new licence carrying a designation indicating authorisation to practise without a practice agreement.

The disclosures a patient can ask for

The parts of these sections a patient can actually use are the disclosure duties, and they are specific.

An advanced practice registered nurse authorised to prescribe shall disclose to the patient at the initial encounter that they are a licensed advanced practice registered nurse. Any party to a practice agreement shall disclose, upon request of a patient or their legal representative, the name of the patient care team physician and information regarding how to contact them.

The physician assistant requirement is written into the regulations the Board of Medicine must promulgate, and the statute specifies its contents: a requirement that the physician assistant disclose to patients their name, address, and telephone number and that they are a physician assistant.

A second duty follows from that one. If a patient or their representative requests to speak with the patient care team physician or podiatrist, the physician assistant shall arrange for communication between the parties or provide the necessary information, unless the assistant is authorised to practise without a practice agreement.

Washington structures the underlying arrangement differently, and the difference is worth noting. Its rules must provide that each physician assistant shall practise medicine only under the terms of one or more collaboration agreements, each signed by the physician assistant and one or more physicians licensed in the state or the physician assistant's employer, and the agreement may be signed electronically by a method the commission approves. The autonomy of the arrangement, and who signs for it, is a state-by-state fact rather than a general one.

Sources

Each document below is named as it names itself, with the date printed on that document rather than the day it was read.

1. Code of Virginia section 54.1-2957, licensure of advanced practice registered nurses, practice agreements and the route to practice without one — Virginia Law, Virginia General Assembly, 2025
2. Code of Virginia section 54.1-2957.01, prescriptive authority of advanced practice registered nurses, disclosure duties and the ceiling on team membership — Virginia Law, Virginia General Assembly, 2025
3. Code of Virginia section 54.1-2952, patient care teams, the six-assistant ceiling and the scope and evaluation requirement — Virginia Law, Virginia General Assembly, 2026
4. Code of Virginia section 54.1-2952.1, physician assistant prescriptive authority and the identity disclosure requirement — Virginia Law, Virginia General Assembly, 2026
5. Revised Code of Washington 18.71A.020, physician assistant collaboration agreements and who may sign them — Washington State Legislature, 2024