Texas NP Supervision Requirements for Medspas

Every NP in Texas needs a Prescriptive Authority Agreement with a supervising physician before prescribing anything. The Texas Board of Nursing licenses NPs, but the Texas Medical Board governs the physician side of the agreement, so the PAA has to satisfy both boards. Texas Occupations Code Chapter 157 sets specific requirements for that agreement that many medspas overlook.

• Written and signed: The PAA must be in writing, signed and dated by both parties, and reviewed at least once a year.
• Medication scope: The agreement must name every medication and device the NP is authorized to prescribe or order, including injectables and prescription-strength treatments.
• Quality assurance meetings: The physician and the NP must meet at least monthly to review cases and prescribing decisions.
• Delegation cap: A physician can delegate prescriptive authority to only seven NPs or PAs at a time, combined and full-time equivalent, with narrow exceptions for medically underserved areas and hospital-based practices.

The more common failure is a PAA that doesn’t name every medication the NP actually prescribes. When a medspa adds a new injectable or weight-loss drug, the Texas Medical Board’s delegation and supervision requirements mean the PAA must be updated too, or the NP is prescribing outside the agreement.

This gap shows up in Texas Board of Nursing scope-of-practice enforcement actions more than almost any other compliance failure. The same cross-reference requirement applies to Texas collaborating physician agreements statewide.

Texas PA Supervision Requirements for Medspas

Physician assistants face a parallel requirement to NPs in Texas. Texas Occupations Code Section 204.204 requires that supervision of a PA be continuous, though it doesn’t require the physician’s constant physical presence. A PA also needs a signed Prescriptive Authority Agreement to prescribe or order drugs.

• Continuous supervision: The physician and the PA must be reachable by phone, radio, or another telecommunication method whenever the PA is working.
• Prescriptive authority: The PA needs a signed PAA naming every medication and device the PA can prescribe or order.
• No sub-delegation: A PA cannot supervise other staff on the physician’s behalf without explicit written authorization.
• Licensed staff only: Unlicensed staff, including most medical assistants, cannot perform delegated medical acts like injections at all.

A PA-operated medspa needs three things in place before a PA touches a patient: the supervising physician named in writing, a PAA covering every medication the PA orders, and a documented process for how the physician stays reachable during clinic hours. Skipping any one of these turns a routine procedure into an unauthorized one, regardless of how experienced the PA is.

Texas Medical Director Requirements — 2026 Overview

A medical director in Texas has to hold an active, unrestricted Texas medical license as an MD or DO. NPs and PAs cannot serve in the role themselves, as they can only perform delegated acts under one. Besides the license, the Texas Medical Board expects a working medical director to meet the standards below.

A medical director who checks every box in this table on paper can still fail an audit if the Texas Medical Board can show the oversight was nominal. That’s the difference regulators actually look for, a director who reviews charts and knows what happened in the practice, not a name on a document with no real interaction with it.

Texas Medical Director Agreement Requirements

A generic medical director template will not satisfy Texas Medical Board expectations. Texas requires delegation language that a standard contract from another state does not include. A compliant agreement needs five elements built in from the start.

• Procedure list: The agreement names each specific procedure being delegated.
• PAA cross-reference: The agreement references the underlying Prescriptive Authority Agreement for any NP or PA on staff.
• Scope of services: The agreement defines exactly what the director oversees.
• Supervision frequency: The agreement sets how often on-site or remote supervision and chart review happen.
• Termination provisions: The agreement spells out how either party can end the arrangement.

The PAA cross-reference and the chart-review cadence are the two elements regulators flag most often during an audit. Agreements copied from another state’s template rarely include either one, since both require language written specifically for Texas’s delegation rules.

Texas Medspa Ownership and Licensing Rules

Texas enforces one of the strictest corporate practice of medicine doctrines in the country. A non-physician cannot own the entity that provides medical aesthetic services such as injectables, laser treatments, or prescription-based therapies. Only a licensed Texas physician, or a professional entity wholly owned by physicians, can hold that side of the business.

• MSO structure: A non-physician entity can handle marketing, staffing, facilities, and administration through a Management Services Organization while a physician-owned entity holds the clinical side.
• PA co-ownership exception: Texas Medical Board rules allow a physician and a physician assistant to jointly own the professional entity, the only non-physician co-ownership arrangement the state recognizes.
• Common in major markets: Dallas, Houston, and Austin medspas frequently use the MSO split to bring in outside investment while keeping clinical control with a licensed physician.
• Additional permits: Most medspas also need a general business license and, depending on services offered, laser or IPL device registration through the Department of State Health Services.

The MSO model only holds up if the operating agreement keeps clinical decisions solely with the physician-owned entity, since regulators treat profit-sharing arrangements that give the non-physician side control over medical judgment as a CPOM violation regardless of how the paperwork is labeled. This is the detail that trips up out-of-state investors who assume Texas allows the same ownership flexibility as states with a looser corporate practice doctrine.

Common Texas Medspa Compliance Mistakes

Most Texas medspa violations trace back to a handful of repeat failures. None of them require a change in law to fix, as they require someone to actually check the paperwork against current staff and services. The list below covers the mistakes that show up most often in Texas Medical Board enforcement actions.

• Expired PAA: An NP prescribes under a Prescriptive Authority Agreement that has lapsed or was never signed for a new medication.
• Out-of-state physician: A supervising physician holds a license in another state but not in Texas, which does not authorize delegation or supervision here.
• Incomplete medication list: The PAA doesn’t name a drug the medspa added after the agreement was signed.
• Undocumented PA supervision: A PA practices without a written, continuous supervision arrangement in place.
• Missing standing orders: A physician gives verbal approval for a procedure instead of a written standing order.
• Absentee medical director: The director is named on the agreement but does not review charts or engage with the practice.

The absentee medical director mistake is the one that turns every other gap into a bigger problem, because a director who is actually reviewing charts tends to catch an expired PAA or an unsupervised PA before it becomes a pattern. Medspas that treat the medical director relationship as ongoing oversight catch these errors internally instead of during a board investigation.

How Medical Director Co. Serves Texas Medspas

Medical Director Co. places Texas-licensed supervising physicians and medical directors for medspas and clinics across the state, including Dallas, Houston, Austin, and San Antonio. Placement takes 24 hours, and every agreement is attorney-reviewed, with delegation and PAA language drafted by in-house healthcare counsel. The flat rate is $799 per month, with no setup fees and no long-term contract. MDCo’s medical director placement services cover the agreement, the delegation protocols, and the ongoing physician relationship, not just a signature on a template.

Get Your Texas Medspa MD in 24 Hours

A missing or lapsed medical director agreement is one of the fastest ways for a Texas medspa to fail an audit. If your current arrangement does not name a Texas-licensed physician, does not reference an updated PAA, or has not seen a chart review in months, that gap is active exposure right now. Replace the agreement, update the PAA, and get a chart review scheduled before the Texas Medical Board finds the gap for you.