This month’s blog posts are all about direct access. Fifty states—plus Washington, DC, and the US Virgin Islands—allow some form of physical therapy without a physician referral. However, the regulations vary from state to state. So, I’m going to break it all down—from AL to WY—in the next four blog posts.

Before we dive into the regulations for every state, I want to mention that I am not a legal expert, and I’ve sourced all of the following information from the APTA and various state association websites. If you have any questions about your state’s law, please consult your state’s practice act, a PT compliance expert, or your attorney. With that, let’s talk direct access from sea to shining sea:

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Alabama

A physical therapist can treat direct access patients when:

  • The patient is a child diagnosed with a developmental disability. Therapy must be in accordance with the child’s plan of care.
  • Physical therapy is in accordance with the plan of care for a patient seen in a home health agency setting.
  • The patient is in a nursing home and physical therapy is in accordance with the plan of care.
  • The patient receives preventative treatment in a wellness setting to prevent injury, provide conditioning, promote fitness, or reduce stress.
  • The patient has received a diagnosis within the last 90 days and physical therapy is seen as appropriate for treating the diagnosed condition. The therapist has to let the patient’s physician know within 15 days of starting physical therapy and provide the physician with a plan of care for the treatment episode.

Alaska

There are no restrictions to direct access in Alaska. However, a physical therapist’s license could be suspended or revoked if the therapist doesn’t refer a patient out of his or her clinic when the scope of care is outside of the therapist’s expertise.

Arizona

There are no restrictions to direct access in Arizona. If a therapist thinks the care is outside of his or her scope, he or she must refer the patient to the appropriate healthcare provider.

Arkansas

When a patient is receiving treatment for bronchopulmonary hygiene, debridement, or wound care, a physician referral is required. There are no other restrictions in this state.

California

A physical therapist can treat direct access patients when:

  • The therapist believes the care falls within the scope of physical therapy. If the therapist thinks the care is outside of his or her scope, or if the patient is not improving or meeting his or her goals, the therapist must refer out to an appropriate healthcare provider.
  • The therapist has told the patient if he or she has any financial interest in treating the patient. If the therapist is working for a physical therapy corporation, he or she must comply with Chapter1, Article 6, commencing with Section 650.
  • After receiving written patient consent, the therapist has notified the patient’s doctor (or surgeon) that the patient is receiving physical therapy care.
  • Therapy does not extend beyond 45 calendar days or 12 visits—whichever comes first—without a signed and dated plan of care. The approved plan of care can come from the patient’s physician, surgeon, or podiatrist. Additionally, the patient’s physician, surgeon, or podiatrist must have examined the patient in person and performed any necessary tests.
  • The patient has been given both written and verbal notice that the therapist can provide treatment for up to 45 calendar days or 12 visits—whichever comes first. The written notice must be in at least 14-point font and signed by the patient. The physical therapist also must notify the patient that physical therapy can be continued (after the aforementioned time frame) only after the patient’s physician, podiatrist, or surgeon has signed a plan of care and has performed an in-person exam of the patient.

With that being said—according to the CPTA—the 12-visit or 45-day limit does not apply to patients with a prior medical diagnosis.

Colorado

A physical therapist can treat direct access patients when:

  • Therapy is within the therapist’s scope of expertise. If a therapist thinks the care is outside of his or her scope, he or she must refer the patient to an appropriate healthcare provider. If the therapist does not refer out when appropriate, he or she will receive disciplinary action.

Connecticut

A physical therapist can treat direct access patients when:

  • The therapist has at least a master’s degree; or, if the therapist has a bachelor’s degree, he or she has practiced physical therapy for at least three of the last six years.
  • The patient shows improvement after six visits or 30 consecutive days—whichever comes first. Following this time period, if upon evaluation (or re-evaluation), the patient’s functional level has not improved both objectively and measurably, then the  therapist must refer the patient to a primary care provider.
  • The patient has disclosed or confirmed the name of his or her primary care provider (or past provider) the first time he or she is seen for physical therapy.
  • “Physical therapy” does not include surgery; prescribing drugs; or diagnosing disease, injury, or illness.”

According to the OLR Bill Analysis, sSB 164, there are three instances when a verbal or written referral is required before a patient can receive physical therapy in Connecticut:

  1. When the therapist knows the condition being treated is connected to a job-related injury.
  2. “If the therapist does not meet the standards mentioned above for direct access.”
  3. “The therapist is required to perform a Grade V spinal manipulation without a PhD in physical therapy (from an accredited university) or without proof that he or she has completed 25 hours of coursework in Grade V spinal manipulation that meets the Physical Therapy Board of Examiners’ minimum standards, and three years of experience in such treatment.”

Regarding work-related injuries, the OLR Bill Analysis, sSB 164 states the following: “A physical therapist does not violate the requirement for a referral to treat work-related injuries if he [or she] asks the patient about the source and nature of his [or her] condition and the patient does not disclose that it ‘arose out of and in the course of the patient's employment.’ This term encompasses an accidental injury or occupational disease that started while the patient was working at the employer's work site or elsewhere at the employer's direction. For a police officer, firefighter, and certain Department of Correction employees, it includes travel to and from home and work.”

DC

A physical therapist can treat direct access patients when the patient has made progress within 30 days of starting therapy. If no progress has been made within 30 days of starting therapy, the patient must be referred to a primary care provider.

Delaware

A physical therapist can treat direct access patients when:

  • Therapy is within the therapist’s scope of expertise. If a therapist thinks the care falls outside of his or her scope, he or she must refer the patient to an appropriate healthcare provider.
  • Treatment is provided for up to 30 days; after that, a physician must be “consulted.”
  • The patient’s prescriptions are not altered or modified by the therapist.

Florida

A physical therapist can treat direct access patients when:

  • Therapy is within the therapist’s scope of expertise. If a therapist thinks the care is outside of his or her scope, he or she must refer the patient to an appropriate healthcare provider.
  • A practitioner on record (meaning the practitioner has a license in the state of Florida) has previously seen the patient. If this has not occurred, then the PT must get a signed plan of care after 21 days.
  • The patient is not being treated in an acute care setting. PTs are not allowed to treat direct access patients who are currently being treated in acute care settings, which include hospitals, ambulatory facilities, surgical centers, and mobile surgical facilities.
  • The PT is not providing chiropractic care, including specific spinal manipulation. The therapist should refer out of the clinic if chiropractic care is necessary.

Learn more on the state site

Georgia

A physical therapist can treat direct access patients when:

  • Physical therapy is used preventatively in a wellness setting to prevent injury, provide conditioning, promote fitness, or reduce stress.
  • A patient was already diagnosed by a physician and has received physical therapy for that same diagnosis within the past 60 days. If this happens, the therapist has to notify the referral source within five business days of the patient coming back for therapy.
  • The PT has a master’s or doctorate degree, or has at least two years of experience as a licensed PT.
  • The patient is improving within 90 days of the first visit. If the patient is not improving, the physical therapist must refer the patient to an appropriately licensed healthcare provider.

Hawaii

There are no restrictions to access in this state. However, if a therapist thinks the care is outside of his or her scope, he or she must refer the patient to an appropriate healthcare provider.


Nothing like finishing a post with a cliffhanger. You might be wondering, “But what about Idaho? Illinois? Iowa?” Don’t worry; I’ll cover the rest of the states in my next three blog posts. Stay tuned. Idaho through Mississippi is comin’ at ya tomorrow.

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