Missouri NP Collaboration Requirements Summary

Missouri NPs must practice under a written collaborative practice arrangement with a collaborating physician. Missouri is a collaborative-practice state with high physician involvement: the physician must be continuously present for the NP’s first month, remain within a practical working distance, be present at least every two weeks, and review a set share of the NP’s charts. There is no pathway to fully independent practice, though NPs who practice exclusively by telehealth are exempt from the in-person proximity rules.

Source: Mo. Rev. Stat. § 334.104

Type of Collaborative Relationship

Missouri NPs must work under a collaborative practice arrangement with a collaborating physician, and there is no route to independent practice. Physician involvement is high: any acts the NP performs must be within the physician’s own skill and training, the physician must be continuously present during the NP’s first month, and the physician must stay close enough that distance does not get in the way of real collaboration. One physician may collaborate with up to six full-time-equivalent advanced practitioners at once. Missouri offers no reduced-supervision or transition tier that removes the collaboration requirement over time.

Source: Mo. Rev. Stat. § 334.104

What is an NP’s scope of practice in Missouri?

Missouri NPs may assess, diagnose, treat, and prescribe, but only within a collaborative practice arrangement and only for acts consistent with each professional’s skill, training, and competence. The arrangement itself defines the delegated methods of treatment and prescribing authority.

Do NPs need a collaborating physician in Missouri?

Yes. Missouri NPs must practice under a written collaborative practice arrangement with a collaborating physician; there is no independent-practice option.

Can NPs practice independently in Missouri?

No. Missouri has no independent-practice pathway. NPs must always work under a collaborative practice arrangement with a collaborating physician.

How many NPs can a physician supervise in Missouri?

Up to six full-time-equivalent advanced practitioners — NPs, physician assistants, and assistant physicians combined. This cap does not apply to hospital employees providing inpatient care.

Who can be a collaborating physician in Missouri?

A physician who is actively engaged in a practice comparable in scope, specialty, or expertise to the NP, and who only delegates acts consistent with his or her own skill, training, and competence. For controlled-substance prescribing, the physician must also hold an unrestricted federal DEA registration.

Are there proximity or in-person requirements in Missouri?

Yes. The physician and NP must stay close enough that distance does not create an impediment to effective collaboration (200 miles by road for correctional-facility settings), and the physician must be present at least every two weeks. NPs practicing exclusively via telehealth are exempt from the proximity requirement.

Collaboration Agreement Requirements

Missouri’s written agreement is called a collaborative practice arrangement, and it must spell out how the NP and physician will work together. It must include the clinicians’ names and contact information, all practice locations, a patient-disclosure notice, each party’s certifications, how they will maintain proximity and provide coverage, the NP’s controlled-substance prescribing authority, the chart-review and every-two-weeks presence terms, referral guidelines, and a process for handling abnormal test results. Both the NP and the collaborating physician must sign and date it before it takes effect. Missouri does not provide a fill-in template, but it does publish a collaboration agreement checklist.

Source: Mo. Rev. Stat. § 334.104(3); 20 CSR 2200-4.200(3)

What must be included in an NP collaborative agreement in Missouri?

The clinicians’ names and contact details, all practice locations, a patient-disclosure notice, each party’s certifications, how they will maintain proximity and provide coverage, the NP’s controlled-substance prescribing authority, the review and every-two-weeks presence terms, referral guidelines, and a process for managing abnormal test results.

What is the collaborative agreement called in Missouri?

It is called a collaborative practice arrangement — Missouri’s term for the written agreement between an NP and a collaborating physician.

Who has to sign the collaborative agreement in Missouri?

Both the NP and the collaborating physician must sign and date it before it is implemented.

How often must the agreement be reviewed or renewed in Missouri?

At least annually. The collaborative practice arrangement must be reviewed at least once a year and revised as needed, and documentation of that review must be kept as part of the arrangement.

Is a backup physician required in Missouri?

Not specifically, but a coverage plan is. The arrangement must describe how coverage will be provided during the collaborating physician’s absence, incapacity, or emergency, though it does not require naming a separate backup physician.

Board Filing Requirements

Missouri does not require the collaborative practice arrangement itself to be filed with the board. NPs may begin practicing once the arrangement is in place. Two filing obligations still apply: for controlled-substance prescribing, the NP must submit a controlled-substance delegation attestation as part of the application, and the collaborating physician must report new collaborations and any changes to the Board of Medicine within 30 days and at each license renewal.

Source: Mo. Rev. Stat. § 334.104(6); 20 CSR 2200-4.200(3)

Do you have to file the collaborative agreement with the board in Missouri?

No. The arrangement does not have to be filed. However, for controlled-substance prescribing the NP must submit a controlled-substance delegation attestation, and the physician must report new collaborations to the Board of Medicine within 30 days.

Can an NP start practicing as soon as they file in Missouri?

Yes. Because the arrangement is not filed for approval, an NP may begin practicing once the collaborative practice arrangement is in place.

What are the termination and notice requirements in Missouri?

The collaborating physician must notify the Board of Medicine within 30 days of any change in collaborators, including a termination.

Collaboration Compliance

Once the collaboration is active, the physician must review the NP’s charts, stay reachable, and be present in person on a set schedule. The physician must review at least 10% of the NP’s total charts every 14 days and at least 20% of charts involving a controlled-substance prescription, must be immediately available for consultation at all times (in person or by telecommunication), and must be present at least once every two weeks. Records of the arrangement, its termination, and the annual review must be kept for at least eight years after the collaboration ends.

Source: 20 CSR 2200-4.200(3)

How many charts must a collaborating physician review in Missouri?

At least 10% of the NP’s total charts every 14 days, plus at least 20% of the charts in which the NP prescribed a controlled substance. Charts must be submitted for review at least every 14 days, in person or electronically.

How often must an NP and collaborating physician meet in Missouri?

At least once every two weeks. The physician must be present for sufficient periods of time at least every 14 days; if the NP provides services via telehealth, that presence may be met by video conferencing.

How long must collaboration records be kept in Missouri?

At least eight years after the collaboration ends. The arrangement, any notice of termination, and documentation of the annual review must all be maintained, and the physician must be able to produce evidence of chart review on request.

Prescribing Rules

Missouri NPs may prescribe as delegated in the collaborative practice arrangement, and controlled-substance authority is limited and requires extra credentials. With a controlled-substance prescriptive-authority certificate, NPs may prescribe Schedules III–V and, within Schedule II, only hydrocodone. Schedule III narcotic and Schedule II hydrocodone prescriptions are limited to a 120-hour supply without refill, and buprenorphine may be prescribed for up to a 30-day supply without refill for patients in medication-assisted treatment. To prescribe controlled substances, the NP must register with the Missouri Bureau of Narcotics and Dangerous Drugs (BNDD) — available only to practitioners with an in-state practice address — and hold a federal DEA registration.

Source: Mo. Rev. Stat. § 335.019(2); Mo. Rev. Stat. § 334.104(2); 20 CSR 2200-4.200(2)(G)

Can an NP prescribe controlled substances in Missouri?

Yes, but only as delegated in the collaborative practice arrangement and only in Schedules III–V plus Schedule II hydrocodone. The NP needs a state controlled-substance prescriptive-authority certificate, a MO BNDD registration (in-state practice address required), and a federal DEA registration.

Can an NP prescribe Schedule II drugs in Missouri?

Only hydrocodone. No other Schedule II drugs may be delegated.

What schedule drugs can an NP prescribe in Missouri?

Schedules III, IV, and V, plus Schedule II hydrocodone only. Schedule III narcotic and Schedule II hydrocodone prescriptions are capped at a 120-hour supply.

Does an NP need a DEA license in Missouri?

Yes. To prescribe controlled substances, an NP must hold a federal DEA registration in addition to a Missouri BNDD registration and the state controlled-substance prescriptive-authority certificate.

Can an NP prescribe independently (without physician sign-off) in Missouri?

No. Prescribing authority — including controlled substances — is delegated through the collaborative practice arrangement, and the collaborating physician retains responsibility for the appropriate prescribing and control of those drugs.

Specialty & Telehealth Requirements

Missouri’s main NP-specific carve-out is for telehealth, which removes the in-person proximity requirement. An NP providing services under a collaborative practice arrangement via telehealth may practice outside the usual geographic-proximity requirement, provided the physician and NP use telehealth and the NP obtains patient consent and protects the confidentiality of medical information. Missouri’s rules also make the collaborating physician responsible for ensuring the NP’s prescribing is appropriate.

Source: Mo. Rev. Stat. § 335.175

Are there telehealth or telemedicine requirements for NPs in Missouri?

Yes. NPs providing services via telehealth are exempt from the geographic-proximity requirement, but must obtain patient consent before telehealth services begin and ensure the confidentiality of medical information.

Are there specialty-specific requirements for NPs in Missouri?

No, Missouri sets no specific specialty requirement in the collaboration rules, aside from the primary care and behavioral health exception that can waive the one-month continuous-presence rule when the physician is new to a patient population the NP already knows.

How do you verify a collaborating physician’s license in Missouri?

Missouri makes physicians’ collaborative practice arrangements public. The Board of Registration for the Healing Arts requires physicians to report their collaborations and makes that information available to the public, so it can be used to confirm a collaborating physician’s arrangements.