Can a Physical Therapist See Patients Without a Referral? Direct Access in Every State

Yes, in every state, in some form. All 50 states and DC let a physical therapist start care without a physician's referral, but only half let you keep going without one for as long as the patient needs. In 25 of the 51, the practice act sets no day or visit limit. The other 26 add a clock, a progress check, a degree or experience requirement, a duty to notify the patient's physician, or a list of procedures that still need a referral.

This article goes through every state for PTs and PTAs: what the act says about evaluating and treating without a referral, the limits, and the exact words of the rule with a link to the official source. Then it covers what Medicare requires, because state direct access doesn't change who has to sign a plan of care. I'm an occupational therapist, not a PT, so I've stayed with what the rules say.

This isn't legal advice. I checked every rule on November 9, 2026, on the state's own legislature, code or board site. Your board's current rule is the one that counts.

The Short Answer

• Direct access exists in all 51 jurisdictions. No state requires a referral before every PT visit. Wisconsin comes closest: its act still requires a written referral, but a board rule exempts treatment of most musculoskeletal injuries.
• No time or visit limit in 25: Alaska, Arizona, Arkansas, Colorado, Hawaii, Idaho, Iowa, Kentucky, Maryland, Massachusetts, Montana, Nebraska, Nevada, New Hampshire, New Mexico, North Carolina, North Dakota, Oregon, South Dakota, Utah, Vermont, Virginia, Washington, West Virginia and Wyoming. Seventeen of them get there simply by having no referral requirement in the act.
• A clock or a progress check in 25. Sixteen set a hard limit, from 21 days in Georgia and Michigan to 120 days in Maine. Twelve make you refer when the patient isn't improving, usually at 30 days. Maine, Missouri and Tennessee do both.
• Who may do it: 11 states add a degree, experience or certificate condition: Alabama, Connecticut, Georgia, Louisiana, Minnesota, Mississippi, Missouri, New York, Pennsylvania, Texas and Virginia.
• Evaluating is easier than treating. Louisiana, Mississippi, Tennessee and Texas let any PT evaluate without a referral even though treatment has conditions. Virginia lets a PT without a DPT or certificate do one evaluation only.
• Home health is different. A Medicare-certified agency needs a physician or allowed practitioner to sign each patient's plan of care, whatever the state allows. Four states write home health into their acts.
• PTAs don't initiate care. The PT evaluates and sets the plan. Oklahoma and Michigan say outright that a PTA may treat during the direct access period.

Every State at a Glance

Not addressed means the state's limit is worded on treatment, and the act doesn't say whether an evaluation alone needs a referral. No referral requirement means the practice act and rules I read have no referral requirement for PT practice, so the quote is the act's definition of practice. Each citation links to the official source I read.

Where the Acts Name Home Health

Four states write home health into the direct access section itself. In each, the care is tied to the agency's plan of care, which in a Medicare-certified agency a physician or allowed practitioner signs. So these clauses mostly switch off the state's clock for home health patients. They don't remove the order.

• Alabama. The 30-day, 11-visit limit "shall not apply" to "A patient of a home health agency pursuant to the agency's plan of care for the patient." (Code of Ala. § 34-24-210.1(d)(2)(b) (opens in a new tab))
• Louisiana. Physical therapy may be performed without a prescription or referral "To a patient of a home health care agency pursuant to the patient's plan of care." (La. R.S. 37:2418(C)(2) (opens in a new tab))
• Mississippi. The same wording, as an exception to its referral rule: "As part of a home health care agency pursuant to the patient's plan of care." (Miss. Code § 73-23-35(3)(b) (opens in a new tab))
• Wisconsin. A written referral is not required if a PT "provides services as part of a home health care agency." (Wis. Stat. § 448.56(1) (opens in a new tab))

If you're a home health PT, the federal section further down matters more to you than any row in the table.

The Clocks: Day and Visit Limits

Sixteen states set a hard limit. When it runs out you need a referral, a signature on your plan, or a consult before you go on.

• Georgia, 21 days or 8 visits. The PT must refer "if after 21 days or eight visits from the initiation of a physical therapy plan" no referral has come from the patient's provider, with exceptions for wellness and for a neuromuscular or developmental condition diagnosed within nine months or a chronic musculoskeletal condition diagnosed within 90 days. The PT also needs a DPT plus two years, a DPT plus a specialty, residency or fellowship, or "Five years of clinical practice experience." (O.C.G.A. § 43-33-18(a)(2), as enacted by HB 505 in 2015 (opens in a new tab); the official code is only on Lexis, and I found no later change to this subsection)
• Michigan, 21 days or 10 treatments. A PT or PTA may treat without a prescription "For 21 days or 10 treatments, whichever first occurs," or for injury prevention and fitness. (MCL 333.17820(1) (opens in a new tab))
• New York, 10 visits or 30 days. "Such treatment may be rendered by a licensed physical therapist for ten visits or thirty days, whichever shall occur first, without a referral" if "The licensed physical therapist has practiced physical therapy on a full time basis equivalent to not less than three years." (Educ. Law § 6731 (opens in a new tab))
• Florida, 30 days. "If physical therapy treatment for a patient is required beyond 30 days for a condition not previously assessed by a practitioner of record, the physical therapist shall have a practitioner of record review and sign the plan." (Fla. Stat. § 486.021(11)(a) (opens in a new tab))
• Oklahoma, 30 days. A PT, including one "operating under a direct-to-employer contract," may evaluate and treat "for a period not to exceed thirty (30) days." The section opens with an exception for workers' comp claims, so those still need a referral. (59 O.S. § 887.17(A)(1) (opens in a new tab))
• Pennsylvania, 30 days, with a certificate. "A physical therapist may treat an individual without a referral as provided for in subsection (b) for up to 30 days from the date of the first treatment." Subsection (b) is the certificate of authorization, which needs two years of practice "on a continuous basis for at least two years immediately preceding the application for a certificate of authorization," professional liability insurance and continuing education. (Physical Therapy Practice Act § 9 (opens in a new tab))
• South Carolina, 30 days. A licensee can be disciplined who, "in the absence of a referral from a licensed medical doctor or dentist, provides physical therapy services beyond thirty days after the initial evaluation and/or treatment date." (S.C. Code § 40-45-110(A)(4) (opens in a new tab))
• Texas, 30 consecutive days. "A physical therapist may treat a patient under Subsection (a) for not more than 30 consecutive calendar days." Subsection (a) requires the PT to have "been licensed to practice physical therapy for at least one year," liability insurance, and either a DPT or "at least 30 hours of continuing competence activities in the area of differential diagnosis." The 2025 amendment (H.B. 4099) set the current text. (Tex. Occ. Code § 453.301 (opens in a new tab))
• Missouri, every 10 visits or 30 days. Even when the patient is improving, "A physical therapist shall consult with an approved health care provider if, after every ten visits or thirty days, whichever occurs first," the PT wants to continue. (RSMo § 334.506 (opens in a new tab))
• Indiana, 42 days. A PT "may evaluate and treat an individual during a period not to exceed forty-two (42) calendar days," then needs a referral. (IC 25-27-1-2.5 (opens in a new tab))
• California, 45 days or 12 visits. The PT "shall not continue treating the patient beyond 45 calendar days or 12 visits, whichever occurs first," without a physician's or podiatrist's dated signature approving the plan, and "Approval of the physical therapist's plan of care shall include an in-person or telehealth patient examination and evaluation of the patient's condition." (Bus. & Prof. Code § 2620.1(a)(4) (opens in a new tab))
• Delaware, Minnesota, Rhode Island and Tennessee, 90 days. Delaware: a physician "must be consulted" after 90 days (24 Del. C. § 2612(a) (opens in a new tab)). Minnesota: an order or referral is needed once "an initial 90-day period of patient admittance to treatment has lapsed" (Minn. Stat. § 148.75(a)(8) (opens in a new tab)). Rhode Island: refer "within ninety (90) days after the date treatment commenced" (R.I. Gen. Laws § 5-40-13(b) (opens in a new tab)). Tennessee: "The physical therapist does not continue physical therapy services for the patient beyond ninety (90) days without consulting with the patient's appropriate healthcare practitioner" (2023 Pub. Ch. 107 (opens in a new tab)).
• Maine, 120 days. "For treatment required beyond 120 days for a condition that has not been medically diagnosed," the PT or PTA consults or refers. (32 M.R.S. § 3113-A(3) (opens in a new tab))

Refer If the Patient Isn't Improving

Twelve states tie the referral to progress instead of, or as well as, the calendar. The trigger is usually 30 days without measurable improvement.

• Connecticut, 30 days or 6 visits. Refer if the condition "does not demonstrate objective, measurable, functional improvement in a period of thirty consecutive days or at the end of six visits, whichever is earlier." (Conn. Gen. Stat. § 20-73(b)(1)(D) (opens in a new tab))
• Illinois and Kansas, 10 visits or 15 business days. Illinois: refer if "the patient does not demonstrate measurable or functional improvement after 10 visits or 15 business days, whichever occurs first" (225 ILCS 90/1.2(c) (opens in a new tab)). Kansas: get a referral if not progressing "after 10 patient visits or in a period of 15 business days from the initial treatment visits following the initial evaluation visit" (K.S.A. 65-2921(a) (opens in a new tab)).
• Alabama, 30 days or 11 visits. "If the patient does not have a beneficial response to the physical therapy in 30 calendar days, or 11 visits, whichever occurs first, the patient shall be referred to a health care provider as appropriate." (Code of Ala. § 34-24-210.1(d)(2) (opens in a new tab))
• 30 days in DC, Louisiana, Maine, Mississippi, Missouri, New Jersey, Ohio and Tennessee. DC: "If a physical therapy patient fails to respond to treatment within thirty (30) days after being seen by a physical therapist for the first time, the physical therapist shall refer the patient" (17 DCMR § 6710.13 (opens in a new tab)). Louisiana: "If, after thirty calendar days of implementing physical therapy treatment pursuant to this Paragraph, the patient has not made measurable or functional improvement, the physical therapist shall refer the patient to an appropriate healthcare provider" (La. R.S. 37:2418(B)(2)(b) (opens in a new tab)). Maine: "If no improvement in the patient is documented by the physical therapist or physical therapist assistant within 30 days of initiation of treatment" (32 M.R.S. § 3113-A(2) (opens in a new tab)). Mississippi: "If the patient has not made measurable or functional improvement after thirty (30) calendar days of implementing physical therapy treatment" (Miss. Code § 73-23-35(4)(c) (opens in a new tab)). Missouri: refer any patient who "does not demonstrate measurable or functional improvement after ten visits or thirty days, whichever occurs first" (RSMo § 334.506.4 (opens in a new tab)). New Jersey's codified rule also requires a referral when the patient hasn't made reasonable progress within 30 days of the first treatment; the 2007 notice that amended the section left that paragraph unchanged and doesn't reprint it. Ohio: consult or refer if "no substantial progress has been made with respect to that patient during the thirty-day period immediately following the date of the patient's initial visit with the physical therapist" (R.C. 4755.481(A)(2) (opens in a new tab)). Tennessee: refer if "no progress has been made with respect to that patient's condition within thirty (30) days" (2023 Pub. Ch. 107 (opens in a new tab)).

Several states switch these rules off for wellness work and for a condition a physician already diagnosed. Georgia, Maine, Ohio and Tennessee name chronic, neuromuscular or developmental conditions.

Degree, Experience and Certificates

Eleven states limit direct access to some PTs:

• A DPT, or years of practice: Louisiana and Mississippi ("The physical therapist has five (5) years of licensed clinical practice experience," Miss. Code § 73-23-35(4)(b) (opens in a new tab)); Missouri (evaluate and treat "provided that the physical therapist has a doctorate of physical therapy degree or has five years of clinical practice as a physical therapist," RSMo § 334.506.2 (opens in a new tab)); Georgia (above).
• A DPT, or a master's and long experience: Alabama ("A physical therapist may not treat patients without a referral from a physical therapy referrer unless the physical therapist possesses a doctorate in physical therapy," or a master's "along with 10 years of clinical practice experience," Code of Ala. § 34-24-210.1(a) (opens in a new tab)); Connecticut (a PT who "earned a master's degree or higher in physical therapy," or entered a bachelor's program before 1998 and has four of the last six years in practice, Conn. Gen. Stat. § 20-73(b)(1)(A) (opens in a new tab)).
• Years of practice alone: New York (three years full time), Minnesota (a PT "licensed less than one year" needs a year of practice in collaboration with an experienced PT or under referral first, Minn. Stat. § 148.75(a)(9) (opens in a new tab)).
• A DPT or a board certificate: Virginia (a PT who completed a DPT program or "obtained a certificate of authorization" may evaluate and treat; anyone else "may conduct a one-time evaluation that does not include treatment of a patient without the referral," Va. Code § 54.1-3482(B)-(C) (opens in a new tab)); Pennsylvania (a certificate of authorization, above).
• Experience plus insurance: Texas (above) and Alabama, which requires liability insurance of "no less than one hundred thousand dollars ($100,000) per occurrence" for any PT treating without a referral (Code of Ala. § 34-24-210.1(j) (opens in a new tab)).

Alabama also carves out cash patients from all of this: "An individual seeking treatment for physical therapy services who is paying cash shall have direct access without restriction." (Code of Ala. § 34-24-210.1(d)(1) (opens in a new tab))

Procedures and Settings That Still Need a Referral

• Spinal manipulation: Connecticut, for a patient who "requires a Grade V spinal manipulation" (§ 20-73(b)(2) (opens in a new tab)); Indiana, "A physical therapist may not perform spinal manipulation of the spinal column or the vertebral column unless" a physician, osteopath or chiropractor examined the patient and referred (IC 25-27-1-2.5(b) (opens in a new tab)).
• Wound debridement: Arkansas, Illinois ("Wound debridement services may only be provided by a physical therapist with written authorization from a health care professional," 225 ILCS 90/1.2(d) (opens in a new tab)), Indiana for sharp debridement, Kansas, and Washington for all wound care.
• Invasive procedures: Virginia, "Invasive procedures within the scope of practice of physical therapy, except for the practice of dry needling, shall at all times be performed only under the referral" of a physician or other listed practitioner (Va. Code § 54.1-3482(D) (opens in a new tab)).
• Recent surgery and concussion: Alabama bars treating anyone "who has undergone a surgical procedure for a diagnosed condition within the previous 90 days without a referral," and anyone with a concussion in the last 45 days unless a physician clears them (Code of Ala. § 34-24-210.1(h) (opens in a new tab)).
• Conditions outside muscle, nerve and bone: Pennsylvania's certificate doesn't cover "a nonneurologic, nonmuscular or nonskeletal condition or to treat an individual who has an acute cardiac or acute pulmonary condition" until the PT consults the patient's physician (§ 9(b) (opens in a new tab)). Wisconsin's exception leaves out "acute fractures or soft tissue avulsions" (PT 6.01 (opens in a new tab)).
• Hospitals: Iowa and Kansas let a hospital require a physician's order for its own patients. In Iowa, "a hospital may require that physical therapy evaluation and treatment provided in the hospital shall be done only upon prior review by and authorization" of its medical staff (Iowa Code § 148A.1(2) (opens in a new tab)).

Most acts also require you to refer a patient whose symptoms are beyond physical therapy. Oregon puts it most plainly: "A licensed physical therapist shall immediately refer a person being treated by the licensed physical therapist to a provider of care if the person exhibits symptoms" that need medical diagnosis, are a contraindication, or are outside your scope (ORS 688.132 (opens in a new tab)).

Notice to the Patient and the Physician

Fourteen states write in a duty to tell someone:

• The patient's physician: Illinois within 5 business days of the first visit; Ohio "not later than five business days after the evaluation is made," with the patient's consent (R.C. 4755.481(A)(1) (opens in a new tab)); Virginia within 14 days when the patient has a current practitioner; Tennessee before treating ("The patient's physician, as defined in § 63-6-204(f)(7), has been notified by the physical therapist," 2023 Pub. Ch. 107 (opens in a new tab)); New Jersey within 30 days; California with the patient's written authorization ("With the patient's written authorization, the physical therapist shall notify the patient's physician and surgeon, if any, that the physical therapist is treating the patient," § 2620.1(a)(3) (opens in a new tab)); Connecticut asks the patient to confirm their primary care provider at each initial visit.
• The patient, in writing: Alabama, California, Georgia, Kansas ("a physical therapy diagnosis is not a medical diagnosis by a physician," K.S.A. 65-2921(e) (opens in a new tab)), New York, Rhode Island ("Disclose to the patient, in writing, the scope and limitations of the practice of physical therapy and obtain his or her consent in writing," § 5-40-13(b)(1) (opens in a new tab)), Texas and Wyoming. Several of these notices are about insurance: Texas's signed disclosure says "the patient's health insurance may not include coverage for the physical therapist's services" (§ 453.301(c) (opens in a new tab)).

Workers' Comp, Medicaid and Insurers in the State Acts

Some acts say outright that direct access doesn't change who pays:

• Workers' comp: Alabama excludes "patients seeking treatment for work-related injuries" (§ 34-24-210.1(d)(1) (opens in a new tab)). Connecticut: "In any case involving an injury, as described in section 31-275, such treatment shall only be performed upon the oral or written referral" (§ 20-73(b)(3) (opens in a new tab)). Maine: "an employer is not liable under Title 39-A, section 206 for charges for services of a physical therapist or physical therapist assistant unless the employee has been referred" (§ 3113-A (opens in a new tab)). Oklahoma's direct access sentence starts with an exception for workers' comp claims. Oregon: "A physical therapist may provide compensable services to an injured worker only as authorized by ORS 656.250" (ORS 688.135 (opens in a new tab)). Louisiana and South Carolina say their direct access rules don't affect their workers' comp laws.
• Medicaid: Mississippi: "Nothing in this section shall restrict the Division of Medicaid from setting rules and regulations regarding the coverage of physical therapy services" (§ 73-23-35(6) (opens in a new tab)). Ohio's act doesn't require reimbursement under "any sickness and accident insurance policy, the medicaid program, or the health partnership program" (R.C. 4755.481(B) (opens in a new tab)), the last being Ohio's workers' comp health program.
• Private insurers: California: "Nothing in this section shall be construed to require a health care service plan, insurer, workers' compensation insurance plan, employer, or state program to provide coverage for direct access to treatment by a physical therapist" (§ 2620.1(d) (opens in a new tab)). Pennsylvania: "Nothing herein shall preclude an insurer or other third-party payor from requiring that a physical therapist obtain a referral" (§ 9(f) (opens in a new tab)). Alabama, Louisiana and Mississippi say the same in their own words.

What This Means for PTAs

Direct access is the PT's to use. In the acts and rules I read, the PT does the initial evaluation and writes the plan, and the PTA treats under it. Iowa's act is typical: the PTA "shall not interpret referrals, perform initial evaluation or reevaluations, initiate physical therapy treatment programs" (Iowa Code § 148A.5 (opens in a new tab)).

A few acts speak to PTAs in the direct access section itself:

• Oklahoma says it outright: "Treatment may be provided by a physical therapist assistant under the supervision of a physical therapist" during the 30 days (59 O.S. § 887.17(A)(1) (opens in a new tab)).
• Michigan lets a PT or PTA treat without a prescription, but "a physical therapist shall determine that the patient's condition requires physical therapy before delegating physical therapy interventions to a physical therapist assistant" (MCL 333.17820(1)(a) (opens in a new tab)).
• Missouri keeps evaluation with the PT: "any authority for evaluation and screening granted within this section may not be delegated" (RSMo § 334.506.5 (opens in a new tab)).
• Maine puts its 30-day and 120-day rules on "the physical therapist or physical therapist assistant" alike (32 M.R.S. § 3113-A (opens in a new tab)), so a PTA carrying the visits shares the duty to flag a patient who isn't improving.
• Pennsylvania keeps a direct access patient with certificate holders: "A certificateholder may not delegate the care of a patient being treated without a referral to a physical therapist who is not a certificateholder" (49 Pa. Code § 40.61(c) (opens in a new tab)).

If you're a PTA in a state with a clock, the clock is running on your visits too. Keep the PT told about visit counts and progress. Our article on which visits a PTA can take covers the scheduling side in home health.

What Changed Recently

APTA's summary map is a good place to start, but several states have changed their text since it was drawn, so I read each act directly. The changes since 2023 that show in the current text:

• Alabama amended its section in 2023 and 2024 (Acts 2023-480 and 2024-385). The current text is the one quoted above.
• Tennessee replaced its section in 2023 (Public Chapter 107) with the notify, 30-day and 90-day structure above.
• Virginia amended its section in 2023. The current text has no day limit.
• Maine amended its section in 2023 (P.L. 2023, c. 317).
• Texas amended its section with H.B. 4099, effective September 1, 2025. The limit now reads 30 consecutive calendar days.
• Oklahoma amended its section in 2025, effective November 1, 2025. The current text names PTs working under direct-to-employer contracts.
• Utah enacted a section titled "No referral required for physical therapy" in 2025 (§ 58-24b-307 (opens in a new tab)).
• Pennsylvania amended section 9(a) on May 6, 2026 (Act 12). It now lets a PT accept a midwife's referral and counts referrers licensed in other states. The 30-day limit and the certificate didn't change.
• Kentucky reenacted its definitions in 2026 (effective July 15, 2026). The board's FAQ still says no referral is needed.

Medicare and Other Payers: Separate From State Law

State direct access decides whether you may treat. It doesn't decide whether anyone pays, and Medicare has its own rules.

Outpatient therapy under Part B

Medicare doesn't require a referral for outpatient therapy, but it does require a certified plan of care. 42 CFR 424.24(c) says Part B pays only if the certification shows "The services were furnished while the individual was under the care of a physician, nurse practitioner, clinical nurse specialist, or physician assistant" and "The services were furnished under a plan of treatment that meets the requirements of § 410.61 of this chapter." When you write the plan, "the certification must be signed by a physician or by a nurse practitioner, clinical nurse specialist, or physician assistant who has knowledge of the case," and "Recertification is required at least every 90 days." (42 CFR 424.24 (opens in a new tab))

There is one exception, and one clarification, in the same paragraph. If there's a written order or referral in the record and you can show you delivered the plan to that practitioner within 30 days of the initial evaluation, no signature is needed. And: "No references to an order or referral in this subsection shall be construed to require an order or referral for outpatient physical therapy, occupational therapy, or speech-language pathology services." (42 CFR 424.24(c)(5) (opens in a new tab))

You can write the plan yourself. 42 CFR 410.61 says "The plan is established before treatment is begun by one of the following," and the list includes "A physical therapist who furnishes the physical therapy services." (42 CFR 410.61(b) (opens in a new tab))

So for a Medicare patient in a state with full direct access, you can evaluate, write the plan and start. The plan still goes to a physician, NP, CNS or PA to certify.

Home health

In a Medicare-certified home health agency, direct access doesn't really come up. The conditions of participation say "Each patient must receive the home health services that are written in an individualized plan of care," one "which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry or allowed practitioner acting within the scope of his or her state license," and "Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner." (42 CFR 484.60(a)(1), (b)(1) (opens in a new tab))

The rule says each patient, not each Medicare patient, so it reaches everyone the agency serves. Your evaluation visit may come before the plan is final, and the rule allows for that: the physician or allowed practitioner "is consulted to approve additions or modifications to the original plan." Our guide to supervisory visit requirements covers what else the CoPs ask of therapy in home health.

Commercial insurance and Medicaid

A commercial plan may still require a referral or a prior authorization for physical therapy, whatever your state's practice act says. So may a state Medicaid program. Several state acts say so in their own text (above). Check the patient's plan before the first visit, and tell the patient if a referral may be needed for coverage.

Key Takeaways

• Every state and DC allows some direct access. No state requires a referral before every visit.
• 25 of the 51 set no day or visit limit. The other 26 add a clock, a progress check, conditions on who may do it, or, in Wisconsin, a referral rule with broad exceptions.
• The common clock is 30 days. The range runs from 21 days in Georgia and Michigan to 120 days in Maine.
• Eleven states limit direct access by degree, experience or certificate, and several still require a referral for spinal manipulation, wound debridement or invasive procedures.
• Direct access is the PT's to use. PTAs treat under the PT's plan, and in states with a clock, PTA visits count.
• Medicare Part B needs a certified plan of care, not a referral. A Medicare-certified home health agency needs a signed plan and orders for every patient, so state direct access doesn't change home health practice.
• This isn't legal advice. I checked every rule on November 9, 2026, on the state's own legislature, code or board site. Your board's current rule is the one that counts.

Frequently asked questions

Can a physical therapist see patients without a referral?

Yes, in some form in all 50 states and DC. In 25 of the 51, the practice act sets no day or visit limit. Another 25 let you start without a referral but set a clock or a progress check, after which you refer, consult or get a signature. Wisconsin still requires a written referral, with exceptions that cover most musculoskeletal injuries. Eleven states also limit who may do it, by degree, years of experience or a certificate.

How long can a physical therapist treat without a referral?

It depends on the state. Sixteen set a hard limit: Georgia 21 days or 8 visits, Michigan 21 days or 10 treatments, New York 10 visits or 30 days, Florida, Oklahoma, Pennsylvania, South Carolina and Texas 30 days, Missouri a consult every 10 visits or 30 days, Indiana 42 days, California 45 days or 12 visits, Delaware, Minnesota, Rhode Island and Tennessee 90 days, and Maine 120 days for a condition no one has diagnosed. Twelve make you refer when the patient isn't improving, usually at 30 days.

Does Medicare require a referral for physical therapy?

Not in so many words. The Part B rule says nothing in it requires an order or referral for outpatient therapy. But Medicare pays only when the therapy plan is certified by a physician, nurse practitioner, clinical nurse specialist or physician assistant, and recertified at least every 90 days. You can evaluate and write the plan. Someone with that authority still has to sign it, unless there is a written order on file and you sent them the plan within 30 days of the evaluation.

Does direct access apply in home health?

Not in a Medicare-certified agency. The home health conditions of participation require a plan of care signed by a physician or allowed practitioner for each patient, and services given only as ordered. So in home health you work from orders whatever your state's practice act allows. Alabama, Louisiana, Mississippi and Wisconsin even write home health into their acts as care given under the agency's plan of care.

Can a PTA treat a patient without a referral?

A PTA treats under a PT's plan, so the direct access question belongs to the PT. Oklahoma says outright that a PTA may provide the treatment under a PT's supervision during the 30 days. Michigan's limit covers a PT or PTA, but the PT must decide the patient needs physical therapy before handing anything to a PTA, and Missouri says the evaluation can't be delegated. In the rules I read, the initial evaluation and the reading of any referral stay with the PT.

Sources

Every state's rule is linked in the table, to the state's legislature, its official code or register publisher, or its PT board. All were read on November 9, 2026. Where a state's code is published only on Lexis (Georgia, Tennessee), I quoted the session law from the legislature or secretary of state, and where a board posts the only free copy of the act (Arkansas, Mississippi), I quoted the board's copy. APTA's direct access map was used only as a pointer to where each state's rule sits.

• 42 CFR 424.24, Requirements for medical and other health services furnished by providers under Medicare Part B (opens in a new tab), paragraph (c).
• 42 CFR 410.61, Plan of treatment requirements for outpatient rehabilitation services (opens in a new tab).
• 42 CFR 484.60, Home health condition of participation: care planning, coordination of services, and quality of care (opens in a new tab).
• Related on this site: supervising PT and PTA students, holding both COTA and PTA licenses and the licensure compact tool.