Muscle, joint & pain

Seeing a Physical Therapist Without a Referral in New Hampshire

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New Hampshire ties its physical therapy referral rule to clinical circumstances, not a clock: no state-mandated visit cap, no fixed calendar deadline. What replaces the countdown is a therapist's ongoing duty to recognize when a case needs a physician instead, plus a distinct state rule requiring written disclosure if a referral is financially compensated. Both shape what direct access actually looks like day to day.

Last updated: July 2026

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Does New Hampshire Require a Referral to See a Physical Therapist?

New Hampshire's Physical Therapy Practice Act does not require a physician referral before a licensed physical therapist can evaluate and begin treating a patient — a therapist can open a case on the strength of their own clinical judgment. Rather than writing in a fixed visit count or calendar-day limit the way some states do, New Hampshire's law ties the referral requirement to what's actually happening in the patient's care, not to a clock.

This kind of care is generally known as direct-access physical therapy. New Hampshire's version puts the responsibility on the physical therapist to recognize, at any point in treatment, when a referral becomes necessary — rather than the law pre-deciding that moment with a number.

When New Hampshire Law Requires a Referral

Under the practice act, a New Hampshire physical therapist must refer a patient to another health care practitioner in two circumstances: when the therapist has reasonable cause to believe the patient's symptoms or condition require services beyond what physical therapy can address, or when physical therapy itself is contraindicated for that patient. Both are clinical judgment calls made by the treating therapist during the course of care, not administrative deadlines a clinic has to track.

That structure puts more weight on a New Hampshire therapist's ongoing screening than a hard cap would. A patient who isn't improving the way expected, or whose exam turns up something outside a musculoskeletal picture, should expect the referral conversation to start well before any arbitrary visit number, because the law was written around the judgment call rather than the calendar.

New Hampshire's Referral-Compensation Disclosure Rule

New Hampshire law requires a physical therapist to tell a patient, in writing, before the first evaluation, if the practitioner who referred them stands to gain financially — directly or indirectly — from that referral. The same section requires a therapist to disclose any financial interest they personally hold in a product they recommend, and to tell every patient plainly that they have freedom of choice in who provides their care and which products they use.

That disclosure requirement exists whether or not a patient came in through direct access, but it matters most in a state without a hard-and-fast direct-access cap: because a New Hampshire therapist's ongoing judgment carries more legal weight than a visit counter, the law adds a transparency rule about who benefits from that judgment. A patient in New Hampshire has a legal right to know if money is changing hands behind a referral, and to choose their own provider regardless.

Why Direct Access Matters in New Hampshire's North Country

New Hampshire is a small state on a map, but travel time doesn't shrink to match. Coos County, the state's northernmost county along the Vermont and Quebec borders, has no hospital-based orthopedic specialist in most of its towns, and a referral requirement for something as ordinary as a strained shoulder could mean a drive south to Berlin, Littleton, or all the way to Lebanon or Manchester just to get the paperwork started.

Direct access removes that detour for the everyday cases — a low back strain, an ankle sprain, a shoulder that's been stiff since a fall on the ice — letting a patient in the North Country see the physical therapist they'd eventually be referred to anyway, without a separate trip first. For routine musculoskeletal pain, skipping the referral step is not skipping care — it's reaching the same care sooner.

How This Interacts With Medicare and New Hampshire Insurance

New Hampshire's practice act settles only the licensing question — whether a physical therapist can legally treat someone without a referral — and says nothing about whether a given insurance plan pays for that visit the way it pays for a referred one. Traditional Medicare does not require a referral to see a physical therapist in a direct-access state, but a physician or other qualified provider still has to certify the plan of care within the first several weeks of treatment, a step the clinic typically manages.

New Hampshire expanded Medicaid eligibility to more low-income adults through the New Hampshire Health Protection Program, which affects how many residents have coverage for physical therapy at all before the referral question comes up. Commercial and employer-sponsored plans can still add their own referral or prior-authorization requirement independent of what state law permits, so a call to the number on the insurance card remains the fastest way to know what a specific plan actually requires.

What the Evidence Says About Starting With a PT First

Research comparing physical therapy episodes that began through direct access with episodes that began after a physician referral found the direct-access episodes involved fewer total visits, less imaging, less medication use, and lower overall cost, without worse outcomes 1. A randomized trial of early physical therapy for people with recent-onset low back pain found a small, statistically significant improvement in disability at three months compared with usual care, though the gap had narrowed and was no longer clinically meaningful by one year 2 — evidence for efficiency, not a case against every referral.

For neck pain, one of the more common reasons someone in New Hampshire might walk into a clinic directly, clinical practice guidelines give physical therapists a structured way to classify the problem and match it to exercise, manual therapy, or education, the same approach whether the visit started with direct access or a physician's note 3.

Confirming New Hampshire's Current Rules Before You Book

State practice acts are amended by the legislature and interpreted through licensing-board rules, so the most reliable way to confirm exactly where New Hampshire stands today is the primary source rather than a secondhand summary, including this one. New Hampshire's Office of Professional Licensure and Certification oversees the Physical Therapy Governing Board and publishes the current version of RSA 328-A along with the board's administrative rules.

A clinic that regularly treats direct-access patients in New Hampshire should be able to explain, in plain terms, when it would refer a patient out and what its compensation-disclosure practice looks like — both are reasonable questions to ask before the first visit.

Common questions

No. New Hampshire's Physical Therapy Practice Act lets a licensed physical therapist evaluate and treat a patient without a physician referral. The therapist must refer the patient to another provider if the condition turns out to need care beyond physical therapy's scope, or if physical therapy itself would be contraindicated.

The law doesn't set a fixed visit count or calendar-day cap the way some states do. Instead, a New Hampshire physical therapist is required to refer a patient out based on clinical judgment — when symptoms suggest something beyond physical therapy's scope, or when physical therapy isn't working the way it should.

If the practitioner who referred a patient to physical therapy would benefit financially from that referral, New Hampshire law requires the physical therapist to disclose this in writing before the first evaluation. Therapists must also disclose financial interests in products they recommend and tell patients they can choose their own provider.

That depends on the plan, not just state law. Traditional Medicare generally doesn't require a referral in a direct-access state but does require a provider to certify the plan of care. Commercial plans and New Hampshire's expanded Medicaid program can each set their own referral or authorization rules, so checking directly is worthwhile.

No. Direct access changes who can start a course of physical therapy, not what a physical therapist is licensed to do. Prescribing medication and ordering imaging still require a physician or another prescribing clinician; a therapist who suspects either is needed is required to refer the patient rather than work around it.

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When to See a Physician Instead of Starting With Physical Therapy

  • —Numbness, weakness, or loss of bladder or bowel control alongside back or neck pain
  • —Pain that began after a fall on ice or another significant trauma
  • —Fever, unexplained weight loss, or a history of cancer alongside new pain
  • —Chest pain, shortness of breath, or lightheadedness brought on by movement

Any of these, especially with sudden or severe symptoms, warrant a same-day physician evaluation or a trip to the emergency room rather than a scheduled physical therapy visit; call 911 for chest pain, severe shortness of breath, or sudden loss of function.

This article explains how direct-access physical therapy generally works in New Hampshire for general education. It is not legal advice and does not replace confirming current requirements with the state licensing board or a specific insurance plan.

References

  1. 1.Ojha HA, Snyder RS, Davenport TE (2014). Direct Access Compared With Referred Physical Therapy Episodes of Care: A Systematic Review. Physical Therapy. PMID 24029295 ✓That direct-access PT episodes were associated with fewer visits, less imaging and medication, and lower cost than referred episodes, without worse outcomes.
  2. 2.Fritz JM, Magel JS, McFadden M, et al. (2015). Early Physical Therapy vs Usual Care in Patients With Recent-Onset Low Back Pain: A Randomized Clinical Trial. JAMA. doi:10.1001/jama.2015.11648 ✓That early PT for recent-onset low back pain produced a small, statistically significant disability improvement at 3 months that was not clinically important by 1 year, versus usual care.
  3. 3.Blanpied PR, Gross AR, Elliott JM, et al. (2017). Neck Pain: Revision 2017 (Clinical Practice Guidelines Linked to the ICF). Journal of Orthopaedic & Sports Physical Therapy. doi:10.2519/jospt.2017.0302That PT clinical practice guidelines give a structured way to classify and treat neck pain with exercise, manual therapy, and education.

3 sources, numbered by first appearance. General health information, not medical advice. AI-assisted editorial content — citations link their sources. Editorial policy

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