Direct Access Laws by State (Alabama-Hawaii)

If you’re a physical therapist—and you’re licensed in the United States—then you’re practicing in a direct access state. That’s right: In all 50 states—as well as the US Virgin Islands and DC—direct access to at least a physical therapy evaluation is the law of the land. But, before you start seeing every patient who walks through your door without a physician referral, there are a few things you ought to know. The laws around direct access can vary greatly depending on which state you practice in. For example, the laws around direct access to physical therapy in California may differ significantly from those in Florida. So, with that in mind, I’m digging through the ins and outs of direct access law by state and presenting you with all the need-to-know facts over the next four days.

Before we get too deep into the thick of things, here’s a quick disclaimer: I’m not a compliance or legal expert, and all of the following information was sourced from this APTA document. So, before you evaluate any direct access patients, be sure to consult with your attorney or a PT compliance professional. With that said, I hope you’re wearing some comfy shoes, ’cause we’re about to cover a lot of ground.

Alabama

• Alabama is one of three states that allow limited direct patient access to a physical therapist.
• Physical therapists may only evaluate patients and/or provide fitness and wellness services and limited treatment:
  • To children with a diagnosed developmental disability if physical therapy aligns with the patient’s care plan.
  • As part of a home health care agency if physical therapy aligns with the patient’s care plan. 
  • To patients in long-term care facilities if physical therapy aligns with the patient’s care plan. 
  • When said services include education, activities, or wellness services for injury prevention, stress reduction, or fitness promotion.
  • To a patient for a previously diagnosed condition for which PT services are deemed necessary. In this scenario:
    • The physical therapist must provide a plan of care to the provider who rendered the diagnosis within the first 15 days of physical therapy intervention.
    • The diagnosis cannot have been made more than 90 days prior to the start of therapy services.

Alaska

• Alaska is one of 20 states that allow patients total, unrestricted access to a physical therapist. No type of physician referral is required for a physical therapist to treat a patient.
• However, if the patient’s condition is beyond the PT’s scope of practice, the therapist is obligated to refer the patient to another qualified healthcare provider. Failure to do so can result in license revocation or suspension.

Arizona

• Arizona is one of 20 states that allow patients total, unrestricted access to a physical therapist. No type of physician referral is required for a physical therapist to treat a patient.
• While direct access to a physical therapist is not restricted in Arizona, a PT must refer a patient to the appropriate healthcare provider if he or she feels the patient’s condition is beyond the physical therapy scope of practice or if physical therapy is contraindicated.

Arkansas

• Arkansas is one of 28 states that allow direct patient access to PT with some provisions.
• In Arkansas, the only provision applies to treatment for bronchopulmonary hygiene, debridement, and wound care. In these instances, a physician referral is required.

California

• California is one of 28 states that allow direct patient access to PT with some provisions.
• To practice via direct access, a PT must:
  • Refer the patient to the patient’s physician if the patient presents with signs of a condition that requires treatment beyond the physical therapy scope of practice.
  • Refer the patient to his or her physician if he or she is not progressing toward documented treatment goals in manner that can be objectively measured.
  • Disclose to the patient any financial interest the therapist has in treating the patient
    • If the PT is working as part of a physical therapy corporation, he or she must comply with Chapter 1, Article 6, commencing with Section 650. 
  • Notify the patient’s physician or surgeon—with the patient’s written authorization—that the patient is being treated by a physical therapist.
  • Provide written or verbal notice to the patient in at least 14-point type to indicate receipt of direct physical therapy treatment services. This notice must also:
    • Note that the patient may continue receiving direct PT treatment for up to 45 calendar days or 12 visits, whichever occurs first.
    • Indicate that after 45 days or 12 visits, the physical therapist may only continue treating the patient with receipt of a dated signature on the physical therapist’s plan of care indicating (1) approval of that plan and (2) that an in-person examination and evaluation was conducted by the appropriate healthcare provider. The only exception is when the PT provides wellness services or PT services under a family service plan or individualized education plan (IEP) and the patient does not have a medical diagnosis. 
    • Be signed by the patient. 
• If treatment lasts longer than 45 calendar days or 12 visits—whichever comes first—the physical therapist must obtain a dated signature on the plan of care from the patient’s healthcare provider.
  • Approval of the plan of care includes an in-person patient exam and evaluation and, if necessary, testing by the patient’s healthcare provider. 
• The PT may not diagnose a disease. 
• A referral and certification are required before the PT can perform tissue penetration.

Colorado

• Colorado is one of 20 states that allow patients total, unrestricted access to a physical therapist. No type of physician referral is required for a physical therapist to treat a patient.
• State law prohibits PTs from diagnosing diseases.
• If a PT believes the patient’s care exceeds the physical therapy scope of practice, the therapist must refer the patient to a qualified healthcare provider. Failure to do so can result in disciplinary action.

Connecticut

• Connecticut is one of 28 states that allow direct patient access to PT with some provisions.
• To practice via direct access, a PT must:
  • Obtain a bachelor’s degree and practice physical therapy for at least four out of the most recent six years, or earn a master’s degree or higher. 
  • Refer a patient receiving PT treatment to an appropriate licensed healthcare provider if, upon examination or reexamination, the therapist determines that the condition for which the patient sought physical therapy has not objectively demonstrated improvement within a period of 30 consecutive days or at the end of six visits, whichever comes first. 
• Grade V spinal manipulation and such treatment shall only be performed by a PT who:
  • Has (1) earned a bachelor’s degree prior to January 1, 1998, and practiced physical therapy for at least four out of the most recent six years, or (2) earned a master’s degree or higher in physical therapy from an accredited institution of higher education; and
  • Holds a specialist certification in orthopedic physical therapy from the American Physical Therapy Association (APTA), or who has completed at least 40 hours of coursework in manual therapy—including Grade V spinal manipulation—and can provide proof of such education. 
• PTs may not diagnose a disease.

Delaware

• Delaware is one of 28 states that allow direct patient access to PT with some provisions.
• Delaware law allows treatment from a PT with or without referral from a licensed medical or osteopathic physician.
• A PT can treat a patient for up to 30 days, after which the therapist must consult a physician.
• If the patient’s condition requires care that falls outside of the PT scope of practice, then the PT must refer the patient to a qualified healthcare provider.
• A PT may not modify a patient’s existing prescriptions.

District of Columbia

• The District of Columbia—along with 28 US states—allows direct patient access to PT with some provisions.
• If the patient does not reasonably progress within 30 days of care, the PT must refer the patient to a primary care provider.

Florida

• Florida is one of 28 states that allow direct patient access to PT with some provisions.
• If the patient’s condition falls outside of the PT scope of practice, the PT must refer the patient to, or consult with, a qualified healthcare practitioner.
• If the PT care plan exceeds 30 days and the condition has not been assessed by a physician of record, then the PT must have a practitioner of record review and sign the plan. However, this does not apply if (1) the patient has been examined by a physician in a different state and diagnosed by the physician as having a condition for which PT is required, and (2) the PT is treating that specific condition. 
• PTs may not implement a treatment plan for patients in an acute care setting such as a hospital, ambulatory surgical center, or mobile surgical facility.

Georgia

• Georgia is one of 28 states that allow direct patient access to PT with some provisions.
• To practice via direct access, a PT must:
  • Obtain a doctorate in physical therapy or an equivalent degree from an accredited institution as well as two years of clinical experience; or 
  • Obtain a doctorate in PT or an equivalent degree in addition to a post-graduate certification, American Board of Physical Therapy Specialties certification, or residency/fellowship training; or
  • Have five years of experience practicing in a clinical setting.
• After 21 days or eight visits—whichever comes first—from the start of the PT plan of care, the PT must obtain a referral from the appropriately licensed healthcare provider unless:
  • The provided services are for health promotion, wellness, fitness, or health maintenance. Furthermore, if the patient presents with symptoms that exceed the PT scope of practice, the physical therapist must refer that patient to a qualified healthcare provider; 
  • The patient received a diagnosis within the last nine months of a neuromuscular or developmental condition and the PT is providing services for symptoms or issues resulting from that previously diagnosed condition; or 
  • The patient received a diagnosis within the last 90 days of a chronic musculoskeletal condition, and the patient can produce current and relevant documentation from an appropriate healthcare provider to confirm that diagnosis.
    • In this instance, the physical therapist must provide a written disclosure to the patient that a diagnosis from a PT and a physician’s diagnosis are not one and the same, and that a PT diagnosis is not reliant on radiological imaging.
    • This disclaimer should also indicate that some PT services might not be covered by the patient’s health insurer.
    • Additionally, the PT must consult with the patient’s primary care provider or physician’s assistant before performing any dry needling treatment on a direct access patient.

Hawaii

• Hawaii is one of 20 states that allow patients total, unrestricted access to a physical therapist. No type of physician referral is required for a physical therapist to treat a patient.
• While direct access to a physical therapist is not restricted in Hawaii, a PT must refer a patient to the appropriate healthcare provider if the therapist feels the patient’s condition is beyond the physical therapy scope of practice or if physical therapy is contraindicated. Failure to do so is considered an act of professional misconduct.

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You might be thinking, “Wait a minute, that’s only 12 states! Didn’t you say that all 50 states are direct access-friendly?” Rest assured: If your state wasn’t covered this time around, I’ll tackle it in one of the next three posts. But, if you’re not a fan of cliffhangers, then you can get all the info you need by downloading our free PT’s Guide to Direct Access Law. Otherwise, I’ll be back Monday—same time, same place—covering direct access laws from Idaho to Mississippi.