Collaborating in Florida

Review to understand how to successfully and compliantly collaborate as a NP or PA in Florida.

State Regulations for Nurse Practitioners

General

• In which category does the state fall: NP independent practice, transition to independence, or collaboration required?
  • Collaboration required, but transition to independence for APRNs engaged in primary care practice.
  • For APRNs engaged in “primary care practice,” they can practice autonomously if they have 3,000 hours of qualifying experience within the prior 5 years.
    • "Primary care practice" includes physical and mental health promotion, assessment, evaluation, disease prevention, health maintenance, counseling, patient education, diagnosis, and treatment of acute and chronic illnesses, inclusive of behavioral and mental health conditions.
    • NP must submit and get approved by BON an Autonomous NP Registration with Financial Responsibility. 

Delegation Authority/Process

• Is an agreement required?

• Yes. Agreement called a "supervisory protocol" is required.

• What form of agreement is required and what are the requirements for the substance of the agreement (is use of state template required?)
  • No specific requirement, but recommendations for what should be included are: 
    • A description of the duties of the ARNP.
    • A description of the duties of the physician or dentist (which shall include consultant and supervisory arrangements in case the physician or dentist is unavailable).
    • The management areas for which the ARNP is responsible, including
    • The conditions for which therapies may be initiated,
    • The treatments that may be initiated by the ARNP, depending on patient condition and judgment of the ARNP,
    • The drug therapies that the ARNP may prescribe, initiate, monitor, alter, or order.
    • A provision for annual review by the parties.
    • Specific conditions and a procedure for identifying conditions that require direct evaluation or specific consultation by the physician or dentist.
  • Details can be found at Florida Board of Nursing Standards for Protocols.
• Where must the agreement be stored?
  • Supervisory protocol must be maintained on-site at the location(s) where an advanced practice registered nurse practices.
• Does the agreement need to be filed with the state?
  • No requirement.
• Are there requirements to file the agreement after the initial filing?
  • Physicians must inform the board of medicine of collaborating relationships and termination of relationships using this form.
    • Notice shall be filed within 30 days of entering into the relationship, orders, or protocol. Notice also shall be provided within 30 days after the physician has terminated any such relationship, orders, or protocol.
• Who must sign the agreement?
  • APRN and supervising physician.
• How often must the agreement be reviewed/reauthorized?
  • No requirement.
• What are the qualifications for the collaborating provider (licensure, same scope, active practice in the state, etc.)?
  • Collaborating provider must be a Florida licensed physician or chiropractor.

Collaboration Requirements

• Are there ratios/limits on the number of NPs that a collaborator may supervise or enter into collaboration agreements?
  • 1 supervisor: 2 or 4 “offices” in addition to the physician's primary office location as stated on the state website. See below the remote supervision section for additional detail.
• Is there an express requirement to review a certain number/percentage of charts?
  • No, but if a physician receives a referral and plans to utilize an NP within their practice: upon initial referral of a patient by another practitioner, the physician receiving the referral must ensure that the patient is informed of the type of license held by the physician and the type of license held by any other practitioner who will be providing services to the patient. When scheduling the initial examination or consultation following such referral, the patient may decide to see the physician or any other licensed practitioner supervised by the physician and, before the initial examination or consultation, shall sign a form indicating the patient’s choice of practitioner. The supervising physician must review the medical record of the initial examination or consultation and ensure that a written report of the initial examination or consultation is furnished to the referring practitioner within 10 business days following the completion of the initial examination or consultation.
• Is there a requirement to meet and, if so, how often and how?
  • See remote supervision requirements below.
• Are there proximity or location-specific requirements?
  • No specific requirement.
• Is remote supervision allowed/are there limitations on remote supervision?
  • Remote supervision permitted so long as the NP is able to contact the practitioner “when needed for consultation and advice either in person or by communication devices.” But see below for specialty specific nuances.
  • A physician who supervises an advanced practice registered nurse or physician assistant at a medical office other than the physician’s primary practice location (a physician’s “primary practice location” means the address reflected on the physician’s profile published pursuant to s. 456.041.), where the advanced practice registered nurse is not under the onsite supervision of a supervising physician, must comply with the standards set forth below:
    • A physician who is engaged in providing primary health care services may not supervise more than four offices in addition to the physician’s primary practice location. For the purpose of this subsection, “primary health care” means health care services that are commonly provided to patients without referral from another practitioner, including obstetrical and gynecological services, and excludes practices providing primarily dermatologic and skin care services, which include aesthetic skin care services.
    • A physician who is engaged in providing specialty health care services may not supervise more than two offices in addition to the physician’s primary practice location. For the purpose of this subsection, “specialty healthcare” means health care services that are commonly provided to patients with a referral from another practitioner and excludes practices providing primarily dermatologic and skin care services, which include aesthetic skin care services.
    • A physician who supervises an advanced practice registered nurse or physician assistant at a medical office other than the physician’s primary practice location, where the advanced practice registered nurse or physician assistant is not under the onsite supervision of a supervising physician and the services offered at the office are primarily dermatologic or skin care services, which include aesthetic skin care services other than plastic surgery, must comply with the standards listed below.
      • The physician shall submit to the board the addresses of all offices where he or she is supervising an advanced practice registered nurse or a physician assistant which are not the physician’s primary practice location.
      • The physician must be board certified or board eligible in dermatology or plastic surgery as recognized by the board pursuant to s. 458.3312.
      • All such offices that are not the physician’s primary place of practice must be within 25 miles of the physician’s primary place of practice or in a county that is contiguous to the county of the physician’s primary place of practice. However, the distance between any of the offices may not exceed 75 miles.
      • The physician may supervise only one office other than the physician’s primary place of practice.
      • All protocols relating to electrolysis or electrology using laser or light-based hair removal or reduction by persons other than physicians licensed in FL shall require the person performing such service to be appropriately trained and work only under the direct supervision and responsibility of a physician licensed in FL.
• Physician and NP filing requirements – outside of filing the collab agreement, must the physician and/or NP file any separate forms? (e.g., notice of delegation of prescriptive authority, notice of collaboration, notice to PDMP, etc.) NOTE: timing/frequency should be noted because the state may have requirements for initial filing and/or filing for updates, terminations, etc.
  • Physicians must inform the board of medicine of collaborating relationships and termination of relationships using this form.
    • Notice shall be filed within 30 days of entering into the relationship, orders, or protocol. Notice also shall be provided within 30 days after the physician has terminated any such relationship, orders, or protocol.

Prescription Requirements

• What are the prescription requirements?
  • If prescribing weight loss drugs is delegated to NP, the delegating physician must review the medical records prior to the issuance of an initial rx, order, or dosage.
• What are the requirements for controlled substance prescribing?
  •  An advanced practice registered nurse may prescribe or dispense a controlled substance as defined in s. 893.03 only if the advanced practice registered nurse has graduated from a program leading to a master’s or doctoral degree in a clinical nursing specialty area with training in specialized practitioner skills.
    • Advanced practice registered nurses may only prescribe controlled substances pursuant to the individual's education, training, experience and protocol.
  • Nurse Practitioner shall not prescribe Schedule II controlled substances via telemedicine except for treatment of a psychiatric disorder.
  • “Psychiatric nurse” means an advanced practice registered nurse licensed under Fla. Stat. Ann. 464.012 who has a master’s or doctoral degree in psychiatric nursing, holds a national advanced practice certification as a psychiatric mental health advanced practice nurse, and has 2 years of post-master’s clinical experience under the supervision of a physician.
    • Advanced practice registered nurses must restrict prescriptions of Schedule II controlled substances as listed in section 893.03, F.S., to a 7-day supply. This restriction does not apply to prescription of controlled substances that are psychiatric medication prescribed by a psychiatric nurse.
    • Only advanced practice registered nurses may prescribe psychiatric mental health controlled substances to children younger than 18 years of age.
  • The following is also prohibited in Florida for psychiatric nurses:
    • Prescribing for office use any medicinal drug appearing in Schedule II of s. 893.03.
    • Prescribing, ordering, dispensing, administering, supplying, selling, or giving a drug that is an amphetamine, a sympathomimetic amine drug, or a compound designated in s. 893.03(2) as a Schedule II controlled substance, to or for any person except for:
      • The treatment of narcolepsy; hyperkinesis; behavioral syndrome in children characterized by the developmentally inappropriate symptoms of moderate to severe distractibility, short attention span, hyperactivity, emotional lability, and impulsivity; or drug-induced brain dysfunction.
      • The differential diagnostic psychiatric evaluation of depression or the treatment of depression shown to be refractory to other therapeutic modalities.
      • The clinical investigation of the effects of such drugs or compounds when an investigative protocol is submitted to, reviewed by, and approved by the department before such investigation is begun.
    • Prescribing, ordering, dispensing, administering, supplying, selling, or giving growth hormones, testosterone or its analogs, human chorionic gonadotropin (HCG), or other hormones for the purpose of muscle building or to enhance athletic performance. As used in this subparagraph, the term “muscle building” does not include the treatment of injured muscle. A prescription written for the drug products identified in this subparagraph may be dispensed by a pharmacist with the presumption that the prescription is for legitimate medical use.
    • Prescribing, ordering, dispensing, administering, supplying, selling, or giving amygdalin (laetrile) to any person.
  • The following is also prohibited in Florida:
    • Prescribing, ordering, dispensing, administering, supplying, selling, or giving a drug that is an amphetamine, a sympathomimetic amine drug, or a compound designated in s. 893.03(2) as a Schedule II controlled substance, to or for any person except for:
      • The treatment of narcolepsy; hyperkinesis; behavioral syndrome in children characterized by the developmentally inappropriate symptoms of moderate to severe distractibility, short attention span, hyperactivity, emotional lability, and impulsivity; or drug-induced brain dysfunction.
      • The differential diagnostic psychiatric evaluation of depression or the treatment of depression shown to be refractory to other therapeutic modalities.
      • The clinical investigation of the effects of such drugs or compounds when an investigative protocol is submitted to, reviewed by, and approved by the department before such investigation is begun.
    • Prescribing, ordering, dispensing, administering, supplying, selling, or giving growth hormones, testosterone or its analogs, human chorionic gonadotropin (HCG), or other hormones for the purpose of muscle building or to enhance athletic performance. As used in this subparagraph, the term “muscle building” does not include the treatment of injured muscle.
    • Prescribing, ordering, dispensing, administering, supplying, selling, or giving amygdalin (laetrile) to any person.

Sources for Reference

• Fla. Stat. Ann. 464.0123
• Fla. Stat. Ann. 464.012
• Fla. Stat. Ann. 464.018
• Fla. Stat. Ann. 456.47
• Fla. Stat. Ann. 458.348
• Fla. Stat. Ann. 459.025
• Fla. Stat. Ann. 893.03
• Fla. Admin. Code Ann. r. 64B9-4.016
• Fla. Admin. Code Ann. r. 64B9-4.020
• Fla. Admin. Code Ann. r. 64B8-9.012; 64B15-14.004
• Fla. Admin. Code Ann. r. 64B9-4.001
• Additional reference: Florida Board of Nursing Standards for Protocols

State Regulations for Physician Assistants

General

• Is the supervising physician responsible for the PA’s patients?
  • Yes. The supervising physician must control the PA’s practice and has responsibility and legal liability for the services rendered by the PA while under their supervision.

• Is an agreement required?
  • A written protocol is required.
• What form of agreement is required and what are the requirements for the substance of the agreement?
  • No specific form is required. A sample protocol for NPs by the Board of Nursing can be used as a reference available here
• Where must the agreement be stored?
  • No specific requirement.
• Does the agreement need to be filed with the state?
  •  PAs to notify the Board in writing within 30 days after employment, or after any subsequent change in the supervising physician using this form
• Are there requirements to file the agreement after the initial filing?
  • Updates must be filed with the board within 30 days of any change in the supervising physician or employment.
• Who must sign the agreement?
  • No specific requirement mentioned.
• How often must the agreement be reviewed/reauthorized?
  • No specific requirement.
• What are the qualifications for the supervising physician?
  • Each physician or group of physicians supervising a PA must be licensed in Florida and qualified in the medical areas in which the PA is to perform.
  • The Board of Medicine may reject a proposed supervisor if the proposed supervisor is not actively engaged in the same or similar specialty area; If under indirect supervision, the proposed supervisor is not practicing within a distance of no more than 20 miles from the applicant's practice location. If under direct supervision, the proposed supervisor is not practicing on the premises.
• Is an alternate supervising physician required?
  • No specific requirement.

Collaboration Requirements

• Are there ratios/limits on the number of PAs that a supervising physician may supervise?
  •  A physician may not supervise more than 10 currently licensed physician assistants at any one time.
  • A physician who supervises a PA at a medical office other than the physician’s primary practice location (means the address reflected on the physician’s profile with the state), where the PA is not under the onsite supervision of a supervising physician, must comply with the standards set forth below:
    • A physician who is engaged in providing primary health care services may not supervise more than four offices in addition to the physician’s primary practice location. For the purpose of this subsection, “primary health care” means health care services that are commonly provided to patients without referral from another practitioner, including obstetrical and gynecological services, and excludes practices providing primarily dermatologic and skin care services, which include aesthetic skin care services.
    • A physician who is engaged in providing specialty health care services may not supervise more than two offices in addition to the physician’s primary practice location. For the purpose of this subsection, “specialty healthcare” means health care services that are commonly provided to patients with a referral from another practitioner and excludes practices providing primarily dermatologic and skin care services, which include aesthetic skin care services.
    • A physician who supervises an PA at a medical office other than the physician’s primary practice location, where the PA is not under the onsite supervision of a supervising physician and the services offered at the office are primarily dermatologic or skin care services, which include aesthetic skin care services other than plastic surgery, must comply with the standards listed in subparagraphs 1.-4.
    • The physician shall submit to the board the addresses of all offices where he or she is supervising a PA which are not the physician’s primary practice location.
    • The physician must be board certified or board eligible in dermatology or plastic surgery as recognized by the board pursuant to s. 458.3312.
    • All such offices that are not the physician’s primary place of practice must be within 25 miles of the physician’s primary place of practice or in a county that is contiguous to the county of the physician’s primary place of practice. However, the distance between any of the offices may not exceed 75 miles.
    • The physician may supervise only one office other than the physician’s primary place of practice.
  • A physician who supervises an office in addition to the physician’s primary practice location must conspicuously post in each of the physician’s offices a current schedule of the regular hours when the physician is present in that office and the hours when the office is open while the physician is not present.
• Is there an express requirement to review a certain number/percentage of charts?
  • No requirement mentioned.
• Are there proximity/location-specific requirements?
  • See above regarding office locations.
  • Florida law identifies two types of supervision:
    • "direct supervision" refers to the physical presence of the supervising physician on the premises so that the supervising physician is immediately available to the PA when needed. Direct supervision appears to be required only in connection with probation/disciplinary action by the board.
    • "indirect supervision" refers to the easy availability of the supervising physician to the PA, which includes the ability to communicate by telecommunications. The supervising physician must be within reasonable/close physical proximity. For allopathic physicians, "close physical proximity" shall be within 20 miles or 30 minutes unless otherwise authorized by the Board.
• Is remote supervision allowed/are there limitations on remote supervision?
  • Remote supervision is allowed unless direct supervision is required for the practice of the PA.
• Are there patient notice requirements?
  • Physician assistant advertisements should disclose the name of the primary supervising physician.
• Physician and PA filing requirements
  •  Supervising physicians must provide notice of intent to delegate dispensing authority to the board, and may do so using this form. The supervising physician must have authority to dispense from the board in order to delegate dispensing authority to a PA.
  • Supervising physicians must provide notice of intent to delegate prescribing authority, and may do so using this form.

Prescription Requirements

• What are the prescription requirements?
  • A supervising physician may delegate to a physician assistant with prescribing authority the ability to procure, prescribe, or dispense only those medicinal drugs as are used in the supervising physician's practice, except (a) General, spinal or epidural anesthetics. (b) Radiographic contrast materials.
  • A PA may only prescribe or dispense such medication under the following circumstances:
    • A PA must clearly identify to the patient that he or she is a PA.
    • The supervising physician must notify the department of his or her intent to delegate, on a department-approved form (see above), before delegating such authority and of any change in prescriptive privileges of the PA. Authority to dispense may be delegated only by a supervising physician who is registered as a dispensing practitioner in compliance with s. 465.0276.
    • A PA may procure medical devices and drugs unless the medication is listed on the formulary created by the applicable board.
    • The PA must complete a minimum of 10 continuing medical education hours in the specialty practice in which the physician assistant has prescriptive privileges with each licensure renewal.
    • The prescription may be in paper or electronic form but must comply with ss. 456.0392(1) and 456.42(1) and chapter 499 and must contain the PA’s name, address, telephone number and the name of each of his or her supervising physicians. Unless it is a drug or drug sample dispensed by the PA, the prescription must be filled in a pharmacy permitted under chapter 465 and must be dispensed in that pharmacy by a pharmacist licensed under chapter 465.
    • The PA must note the prescription or dispensing of medication in the appropriate medical record.
• What are the requirements for controlled substance prescribing?
  • PAs may prescribe controlled substances, as defined in Chapter 893, F.S., with the following restrictions:
    • PAs may only prescribe a 14-day supply of Schedule II psychiatric mental health controlled substances for children younger than 18 years of age provided the PA is under the supervision of a pediatrician, a family practice physician, an internal medicine physician, or a psychiatrist.
    • PAs may only prescribe a 7-day supply of all other Schedule II controlled substances as listed in Section 893.03,

Sources for Reference

• Fla. Stat. § 458.347
• Fla. Stat. § 459.022
• 64B8-2.001, F.A.C.
• 64B15-6.001, F.A.C.
• 64B8-30.001, F.A.C.
• 64B8-30.008, F.A.C.
• 64B8-30.011, F.A.C.
• 64B8-4.025, F.A.C.