Most important takeaways…
- A Wake County nurse practitioner sued state medical and nursing board leaders.
- She pays $16,500 a year for a collaborative practice agreement.
- The lawsuit claims the requirement is unconstitutional and seeks only $1.
Some North Carolina nurse practitioners pay nothing beyond state licensing fees to practice; Jamie Gallagher pays her collaborating physician $16,500 a year, and that physician is not required to see her patients, review her charts, or directly supervise her care.
That payment sits at the center of a lawsuit Gallagher filed in Wake County Superior Court against the leaders of the state medical and nursing boards. The case challenges whether North Carolina's collaborative practice agreement requirement violates the state constitution, with potential ripple effects for NP scope of practice expansion far beyond state lines.
With 93 of 100 North Carolina counties designated Health Professional Shortage Areas, the economic and access stakes extend well past one NP's annual check.
The Lawsuit: Who Filed, Against Whom, and Why
In September 2026, nurse practitioner Jamie Gallagher filed a lawsuit in Wake County Superior Court directly challenging North Carolina's mandatory collaborative practice agreement (CPA) law, which keeps the state from being counted among full practice authority states.1 Gallagher, a family nurse practitioner with more than 17 years of experience, named two state officials as defendants: Anuradha Rao-Patel, president of the North Carolina Medical Board, and Racquel Ingram, chair of the North Carolina Board of Nursing.2
The claims
Gallagher is represented by the Pacific Legal Foundation and North Carolina attorney Dan Gibson. The suit asks the court to declare one statute and four state regulations unconstitutional as applied to Gallagher and other nationally certified NPs. It requests declaratory relief, only $1 in damages, and court costs.2
Current status
As of early September 2026, the case is active. No motions, hearing dates, or rulings after the September 2 filing have been publicly confirmed. The North Carolina Medical Board has declined to comment on pending litigation, and no public statement from the Board of Nursing has appeared in court records or press coverage. For the latest docket activity, check the Wake County Clerk of Court.
What Is a Collaborative Practice Agreement, and What Does It Cost in North Carolina?
Across North Carolina, the collaborative practice agreement has quietly shifted from a clinical safeguard into a recurring business cost for many nurse practitioners.
What the law requires
Under North Carolina law, a collaborative practice agreement, or CPA, is a contract between a nurse practitioner and a supervising physician. Without it, an NP cannot legally practice in the state , a key restriction on nurse practitioner scope of practice. The agreement is meant to ensure physician oversight, but the actual terms often leave the day-to-day clinical decisions in the NP's hands.
The price of a signature
In the lawsuit, Jamie Gallagher reports paying her collaborating physician $16,500 per year. Under the arrangement, the physician is not required to see her patients, review her charts, or directly supervise her care. Her experience is not unusual: NP supervision costs and terms vary widely by specialty and region, and some NPs pay thousands of dollars annually for little more than a signed document.
That gap between payment and meaningful oversight is central to the legal argument that follows. If the state treats a paid signature as adequate supervision, critics ask, what clinical value is the CPA actually providing?
The Constitutional Arguments Behind Gallagher V. Rao-Patel
The lawsuit's core claim is that North Carolina's collaborative practice agreement law offends both fundamental rights and equal protection under the state constitution. Gallagher argues that Article I, Section 1 protects the right to pursue a lawful profession, while Section 19 requires due process and equal treatment. By requiring an NP to obtain a private physician's signature before practicing, the state delegates its licensing power to a private party with no public accountability or clinical oversight standard. That private gatekeeper can demand payment, as Gallagher's $16,500 annual CPA shows, without reviewing charts or seeing patients.
What Connette Already Established
The 2022 North Carolina Supreme Court ruling in Connette v. Charlotte-Mecklenburg Hospital Authority removed the old liability shield for nurses acting under physician supervision. The court recognized the increased specialization and independence of nurses, a pattern visible in the history of nurse practitioners, and held that APRNs may be held liable for medical malpractice even under physician supervision if they breach the standard of care.1 That decision framed independence as added accountability. Gallagher's suit asks the court to take the next logical step: if NPs are independently accountable, they should not need a private collaborator's permission to practice. With 93 of 100 counties designated Health Professional Shortage Areas, the legal theory carries practical urgency for nurse practitioners in rural healthcare.
Gallagher is seeking only $1 in damages, plus costs and other legal relief.
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How NC's Collaborative Practice Rules Compare to Full Practice Authority States
North Carolina remains a restricted practice state, meaning nurse practitioners cannot practice without a written collaborative practice agreement. The table below compares that model with three long-standing full practice authority states. North Carolina's official annual renewal fee is $50, but the private collaborative agreement can add substantial cost, as one Wake County NP reports paying $16,500 per year.
| State | Practice Authority Status | Physician Agreement Required? | Typical Annual Cost/Fee | Key Requirement |
|---|---|---|---|---|
| North Carolina | Restricted practice; collaborative practice agreement with a physician is required | Yes; written collaborative practice agreement with a supervising physician | $50 annual renewal fee (application fee $100) | Approval tied to the collaborative practice agreement with a physician; application fee $100 and annual renewal fee $50 |
| Arizona | Full practice authority; NPs may practice and prescribe independently without physician involvement | No; no collaborating physician, written agreement, or physician supervision required | N/A | NPs practice under the Arizona State Board of Nursing alone; no agreements, ratios, chart reviews, or transitional periods at any career stage |
| Oregon | Full practice authority; long permitted independent NP practice | No; physician supervision or collaboration not required | N/A | NP must provide health care services only within the NP's educational preparation and competency scope |
| Colorado | Full practice authority after transitional prescriptive period | No ongoing collaboration; collaborating clinician required only during provisional prescriptive authority | N/A | During provisional prescriptive period, NP must complete a 750-hour prescribing mentorship under a written Mutually Structured Mentorship Agreement with synchronous contact |
How to Stay Informed and Support NC Practice Authority Efforts
To stay current on a fast-moving court case while working clinical shifts, choose a few high-signal sources rather than chasing every update. Gallagher v. Rao-Patel is moving through Wake County Superior Court, and three organizations make it easier to follow the case and push for change.
Track the Case and the Policy Campaign
- Pacific Legal Foundation: The firm's Gallagher v. Rao-Patel case page hosts the complaint, status updates, and plain-language explanations of the constitutional arguments.
- North Carolina Nurses Association: NCNA leads the SAVE Act campaign for APRN full practice authority. It offers weekly volunteer slots at the North Carolina General Assembly and an online messaging tool that sends your note directly to state legislators.
- American Association of Nurse Practitioners: AANP publishes a state practice environment map updated in May 20261 and maintains a State Legislation Tracking Center2 so you can compare North Carolina with full practice authority states.
Use these tools from the NP Health Policy Toolkit to contact your state representative or senator when SAVE Act bills are introduced. Personal messages from working nurse practitioners carry weight with lawmakers. If the bill passes, North Carolina would become the 28th full practice authority state, a milestone backed by more than 29 outside organizations.
Go to Primary Sources When You Need More
If you want the raw filings, Wake County Superior Court's public docket can be monitored through North Carolina's court records portal. The Pacific Legal Foundation case tracker summarizes those filings in plain language, which is often faster for a busy clinician.
