Missouri PA Collaboration Requirements Summary

Missouri requires every PA to work under a written collaborative practice arrangement with a collaborating physician who is at all times responsible for overseeing the PA’s activities and accepts responsibility for the services the PA renders. Involvement is high and physically demanding: the physician must first work alongside the PA for a documented period, then remain present at least once every two weeks in settings where the PA diagnoses and starts treatment for acutely or chronically ill patients. Chart review runs on a 14-day cycle — 10% of all charts, and 20% of charts involving controlled substances. Prescribing is where Missouri is most restrictive: PAs are limited to Schedules III through V plus hydrocodone in Schedule II, need both federal and state registrations, and must log 120 on-site hours before prescribing controlled substances without the physician present. This page covers Missouri’s rules on collaboration, the collaborative practice arrangement, board filing, ongoing compliance, prescribing, and specialty and telehealth requirements.

Source: Mo. Rev. Stat. § 334.735(7)

Type of Collaborative Relationship

Missouri requires PAs to practice under a collaborating physician at all times, with no route to independent practice and no transition pathway. Involvement is high and includes real in-person obligations: a documented starting period working side by side, and continuing physician presence every two weeks in acute and chronic care settings. A PA’s authority comes from the written collaborative practice arrangement and is capped by the collaborating physician’s own scope of practice, and one physician may collaborate with no more than six full-time-equivalent advanced practice providers.

Source: Mo. Rev. Stat. § 334.735(13)

What is a PA’s scope of practice in Missouri?

A PA’s scope of practice is set by the collaborative practice arrangement and must be consistent with both the PA’s and the collaborating physician’s scopes of practice. The arrangement must describe how the two will engage in collaborative practice consistent with each professional’s skill, training, education, and competence.

Do PAs need a collaborating physician in Missouri?

Yes. Every PA must work under a written collaborative practice arrangement with a collaborating physician, and a PA may not begin practicing until they have informed the Board in writing of that physician’s name and practice addresses.

Can PAs practice independently in Missouri?

No. Missouri has no independent or autonomous practice option for PAs and no pathway that reduces oversight over time. The collaborating physician is at all times responsible for overseeing the PA’s activities and accepts responsibility for the health care services the PA renders.

How many PAs can a physician collaborate with in Missouri?

No more than six full-time equivalents. That limit counts licensed PAs, advanced practice registered nurses, and assistant physicians together, in any combination. It does not apply to PA collaborative practice arrangements of hospital employees providing inpatient care services in hospitals.

Who can be a collaborating physician in Missouri?

The collaborating physician must hold a permanent license to practice medicine in Missouri and be actively engaged in the practice of medicine. A practical limit also applies to prescribing: a PA may not prescribe anything the collaborating physician is not qualified or authorized to prescribe.

Are there proximity or in-person requirements in Missouri?

Yes — Missouri has several. Before a PA practices in a setting where the collaborating physician is not continuously present, the physician must determine and document completion of a period during which the PA practiced with them continuously present. Where the PA delivers care that includes diagnosing and initiating treatment for acutely or chronically ill or injured persons, the physician must be present for sufficient periods of time at least once every two weeks, except in extraordinary circumstances that must be documented. If the PA is using telehealth to provide services, that collaboration may occur via telehealth rather than in person.

Collaboration Agreement Requirements

Missouri’s written agreement is called a collaborative practice arrangement, and the state provides no template. Both the collaborating physician and the PA sign and date it before it takes effect, and it must be reviewed at least annually and revised as they see fit. Missouri’s required contents are unusually detailed — they include the chart review percentages written into the document itself and a patient-facing disclosure sign.

Source: 20 CSR 2150-7.135(5)

What must be included in a PA collaborative agreement in Missouri?

The arrangement must include both parties’ complete names, addresses, and telephone numbers, all specialty and board certifications, every other location where the physician has authorized the PA to prescribe, a list of all other collaborative practice arrangements either of them holds, and the arrangement’s duration. It must set out the manner of collaboration — how the two will practice consistent with each professional’s competence, maintain geographic proximity, and provide coverage during the physician’s absence — along with the time and manner of chart review including the 10% and 20% minimums, and consultation, transportation, and referral procedures for patients needing emergency care or care beyond the PA’s scope. It must also require a prominently displayed disclosure at every office where the PA is authorized to prescribe, telling patients they may be seen by a PA and have the right to see the collaborating physician.

What is the collaborative agreement called in Missouri?

It is called a collaborative practice arrangement. Missouri does not provide a template.

Who has to sign the collaborative agreement in Missouri?

The collaborating physician and the PA must both sign and date it before it is implemented.

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

At least annually. The collaborating physician and the PA must review the arrangement each year and revise it whenever they deem it necessary.

Is a backup physician required in Missouri?

No — Missouri does not require a named backup physician. The arrangement must, however, describe how coverage will be provided during the collaborating physician’s absence, incapacity, infirmity, or emergency. Missouri provides no grace period allowing a PA to keep practicing if the collaborating physician unexpectedly becomes unavailable.

Board Filing Requirements

Missouri requires PAs to file a copy of their collaborating physician form with the Board, and a PA may not practice until the Board has been informed in writing of the collaborating physician’s name and practice addresses. Physicians carry their own reporting duty, both on change and at each license renewal. Changes run on two different clocks: 15 days for the PA, 30 days for the physician.

Source: Mo. Rev. Stat. § 334.735(15)

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

Yes. PAs must file a copy of their collaborating physician form with the Board. Separately, every physician must identify to the Board whether they are engaged in any collaborative practice arrangement — including arrangements delegating controlled substance prescribing — and report the name of each PA involved.

Can a PA start practicing as soon as they file in Missouri?

A PA may not practice until they have informed the Board in writing of the collaborating physician’s name and practice addresses. Once that notification is made, Missouri does not require the PA to wait for Board approval.

What are the termination and notice requirements in Missouri?

A PA who has a change in a collaborative practice arrangement, for any reason, must submit written notification and the required form to the Board within 15 days. The collaborating physician must report any change within 30 days and again at each license renewal. Missouri provides no grace period allowing the PA to keep practicing in the meantime.

Collaboration Compliance

Chart review on a 14-day cycle is the center of Missouri’s ongoing obligations: 10% of all charts, plus 20% of charts where the PA prescribed controlled substances. Alongside that, the collaborating physician carries documentation duties — recording the initial period of working together, the 120 on-site hours where controlled substance prescribing is involved, and the chart review itself. Missouri prescribes no meeting cadence, requires no chart co-signature, and sets no availability standard, though the two-week presence requirement applies in acute and chronic care settings.

Source: Mo. Rev. Stat. § 334.735(9)(8),(9)

How many charts must a collaborating physician review in Missouri?

At least 10% of all charts documenting the PA’s delivery of health care services, every 14 days. Separately, at least 20% of the charts in which the PA prescribed controlled substances must be reviewed every 14 days — and those may be counted toward the 10%. Reviews may be conducted electronically, and either the collaborating physician or another physician designated in the arrangement may perform them.

How often must a PA and collaborating physician meet in Missouri?

Missouri prescribes no meeting cadence, but it does require physician presence in some settings. Where the PA provides care that includes diagnosing and initiating treatment for acutely or chronically ill or injured persons, the collaborating physician must be present for sufficient periods of time at least once every two weeks — except in documented extraordinary circumstances — to take part in chart review and provide medical direction, services, consultation, and supervision. If the PA is using telehealth, that collaboration may occur via telehealth.

How long must collaboration records be kept in Missouri?

Missouri sets no specific retention period. The collaborating physician must document completion of the initial period of continuous presence and, where controlled substance prescribing is involved, the 120 on-site hours. The physician must also produce evidence of the required chart review on request of the Missouri State Board of Registration for the Healing Arts.

Prescribing Rules

PAs in Missouri may prescribe drugs, medications, devices, and therapies consistent with both their own and the collaborating physician’s scopes of practice, and may never prescribe anything the physician is not qualified or authorized to prescribe. Controlled substances require two registrations — federal DEA and the Missouri Bureau of Narcotics and Dangerous Drugs — and the state registration is available only to practitioners with an in-state practice address. Missouri also limits PAs by schedule and requires 120 documented on-site hours before a PA prescribes controlled substances with the physician off-site.

Source: Mo. Rev. Stat. § 334.735(8)

Can a PA prescribe controlled substances in Missouri?

Yes, where the collaborative practice arrangement delegates that authority. The PA must register with both the federal DEA and the Missouri Bureau of Narcotics and Dangerous Drugs, and must include the DEA registration number on controlled substance prescriptions. The state registration is available only to practitioners who practice from an in-state address.

Can a PA prescribe Schedule II drugs in Missouri?

Only hydrocodone, with one exception. A collaborative practice arrangement may delegate Schedule II authority for hydrocodone only, and those prescriptions are limited to a 120-hour supply without refill. The exception is hospice: a PA employed by a certified hospice provider may prescribe Schedule II medications for hospice patients, provided the arrangement designates the certified hospice as a location where the PA is authorized to practice and prescribe.

What schedule drugs can a PA prescribe in Missouri?

Schedules III, IV, and V, plus hydrocodone in Schedule II. Schedule III narcotic controlled substances and Schedule II hydrocodone prescriptions are capped at a 120-hour supply without refill. Everything a PA prescribes must also fall within the collaborating physician’s own scope of practice, and Missouri sets no special prescription pad requirements.

Does a PA need a DEA license in Missouri?

Yes — a PA authorized to prescribe controlled substances must register with the federal DEA, and the DEA registration number must appear on controlled substance prescriptions. Missouri additionally requires registration with the state Bureau of Narcotics and Dangerous Drugs, which is available only to practitioners with an in-state Missouri practice address.

Can a PA prescribe independently (without physician sign-off) in Missouri?

No. A PA may not prescribe anything the collaborating physician is not qualified or authorized to prescribe, and prescribing authority flows from the collaborative practice arrangement. Individual prescriptions do not require co-signature, but at least 20% of controlled substance charts must be reviewed every 14 days, and the PA must complete 120 documented on-site hours over a four-month period before prescribing controlled substances when the physician is not on-site.

Specialty & Telehealth Requirements

Missouri has one telehealth-specific requirement for PAs — patient consent — and no specialty-specific requirements. A few settings do carry their own carve-outs from the general collaboration rules.

Source: 20 CSR 2150-7.135(6)

Are there telehealth or telemedicine requirements for PAs in Missouri?

Yes — consent. A telehealth provider must obtain the patient’s or the patient’s guardian’s consent before telehealth services are initiated, and must document that consent in the patient’s file or chart. Telehealth also changes how collaboration can happen: when the PA delivers services by telehealth, the collaborating physician’s required presence may be satisfied via telehealth rather than in person.

Are there specialty-specific requirements for PAs in Missouri?

No — Missouri sets no specialty-specific requirement for PAs. Two setting-based carve-outs are worth knowing: PAs who are hospital employees providing inpatient care services are excluded from the six-provider limit, and a physician-PA team working in a certified community behavioral health clinic, a rural health clinic, or a federally qualified health center is subject to no collaboration requirements beyond federal law.