Starting a practice in Germany: roadmap and checklist with all deadlines

The roadmap: from decision to opening

With a private practice or a physiotherapy practice, you can complete the set-up in six to twelve months. If you want to take over a Kassensitz (practice seat with statutory insurance approval), allow twelve to 18 months, because advertised seats and the meeting dates of the Zulassungsausschuss (admissions committee) set the pace.

Approbation, licence and chamber

Every practice is based on the state licence to practise your profession. After that, the three professions differ considerably:

• Chamber: membership arises by law, but you have to register yourself. The deadline is set in the Heilberufe-Kammergesetz (Healthcare Professions Chamber Act) of your federal state and is usually one month after starting your activity, less in some states.
• Gesundheitsamt: in some federal states, you also have to notify the public health office at your practice location when you start working self-employed, e.g. in Hesse within one month (§ 12 HGöGD) or in Bavaria. There, this often applies to physiotherapists too. Ask your Gesundheitsamt.
• Psychologists without an Approbation may practise healing only with a Heilpraktiker licence (alternative practitioner licence) limited to psychotherapy, and may not bill the GKV (statutory health insurance).

Statutory insurance approval, needs-based planning or private practice

Doctors and psychotherapists: KV approval

To treat patients with statutory insurance, you need an approval from the Zulassungsausschuss of your Kassenärztliche Vereinigung (§ 95 SGB V). The prerequisite is entry in the Arztregister. Whether a seat is available is determined by needs-based planning (Bedarfsplanung): if the level of provision for a group of doctors in a planning area exceeds demand by 10 % or more, the area counts as oversupplied and is closed (§§ 101, 103 SGB V). Then you can usually only get in by taking over an advertised seat, where the committee chooses among the applicants.

• Deadlines: the Zulassungsausschuss meets at fixed intervals. Complete applications must be submitted in good time before the meeting; your KV publishes dates and submission deadlines.
• Proof: with your application, you submit the insurance certificate for your professional liability insurance (§ 95e Abs. 3 SGB V).
• Start: in its approval decision, the committee sets the date by which you must start practising (§ 19 Abs. 2 Ärzte-ZV).

Physiotherapists: approval under § 124 SGB V

There is no needs-based planning for Heilmittel (therapeutic services). The working group of the regional associations of the health insurance funds and the substitute funds grants approval if you hold the professional licence, the practice is appropriately equipped and you accept the contracts under § 125 SGB V. Among other things, the nationwide contract requires at least 23 m² of therapy space (one area of 15 m², one of 8 m²) and a clear ceiling height of 2.40 m. With your application, you submit the lease, a floor plan with the areas and a list of equipment.

The alternative: private practice

Without approval, you treat privately insured patients, Beihilfe recipients (civil servants with state healthcare allowance) and self-payers, and bill according to the GOÄ or GOP (fee schedules for doctors and psychotherapists). This is quicker, but requires a clear offer and good visibility. More on this in the guides opening a private practice, setting up a psychotherapy practice and setting up a physiotherapy practice. Psychologists without an Approbation bill privately, see setting up a psychology practice.

Insurance: liability, retirement provision, health insurance, BGW

• Professional liability insurance: for doctors and psychotherapists, it is required by the chamber act and the professional code; for doctors without adequate insurance, the Approbation can even be suspended (§ 6 Abs. 1 Nr. 5 BÄO). With statutory insurance approval, the minimum sum of €3 million per insured event applies. Physiotherapists shouldn’t go without it either, even though no law specifies a sum.
• Versorgungswerk: doctors are compulsory members of the Versorgungswerk of their Landesärztekammer. For psychotherapists, depending on the federal state, there is either a separate Versorgungswerk or affiliation with that of another state; your chamber will tell you which one is responsible.
• Pension insurance (physiotherapy): self-employed physiotherapists without employees subject to compulsory insurance are generally subject to compulsory pension insurance (§ 2 Satz 1 Nr. 2 SGB VI). You must register with the Deutsche Rentenversicherung (German statutory pension insurance) within three months (§ 190a SGB VI).
• Health and long-term care insurance: as a full-time self-employed person, you are no longer compulsorily insured (§ 5 Abs. 5 SGB V). If you had statutory insurance, it automatically continues as voluntary membership, unless you leave within two weeks of being notified by your insurance fund and prove other cover (§ 188 Abs. 4 SGB V). Long-term care insurance follows your health insurance. Consider daily sickness allowance insurance.
• BGW: your practice is a member of the Berufsgenossenschaft für Gesundheitsdienst und Wohlfahrtspflege (statutory accident insurer for health and welfare services). You must register within one week of opening (§ 192 SGB VII), even without employees. Employees are then automatically covered by accident insurance. Self-employed physiotherapists are compulsorily insured themselves (§ 2 Abs. 1 Nr. 9 SGB VII); doctors and psychotherapists are exempt (§ 4 Abs. 3 SGB VII) and can insure themselves voluntarily.

Tax office: a liberal profession, not a trade

Doctors and Krankengymnasten (the traditional German term) or physiotherapists are explicitly listed as liberal professions (§ 18 Abs. 1 Nr. 1 EStG), and psychotherapists count as a similar profession. So you don’t register a trade and pay no trade tax. Instead, you notify the tax office that you have started your activity: with the Fragebogen zur steuerlichen Erfassung, electronically via ELSTER, within one month (§ 138 Abs. 1, 1b and 4 AO). You then receive your tax number.

Medical treatments by doctors, physiotherapists and similar healthcare professions are exempt from VAT (§ 4 Nr. 14 Buchst. a UStG). In return, you generally cannot deduct input VAT on your purchases. So calculate equipment, alterations and your website including VAT.

Premises: change of use, accessibility, hygiene

• Change of use: turning a flat or a shop into a practice is often a change of use requiring a permit under the building code of your federal state. In cities with a Zweckentfremdungsverbot (ban on using housing for other purposes), such as Berlin, Hamburg or Munich, you also need a permit for residential space. Clarify both before signing and have the lease guarantee use as a practice.
• Accessibility: the state building codes require accessibility for publicly accessible buildings in new builds and major alterations. When a Kassensitz is filled again, the needs of people with disabilities are among the selection criteria (§ 103 Abs. 4 SGB V). Under the contract with the insurance funds, new premises for physiotherapy practices should be accessible, and the GKV directory shows this.
• Hygiene: as head of the practice, you are responsible for ensuring that hygiene meets the current state of science (§ 23 Abs. 3 IfSG). Many federal states require hygiene plans for practices performing invasive procedures.

Data protection and confidentiality

• Specially protected data: health data falls under Art. 9 GDPR, plus professional confidentiality (§ 203 StGB). You need a record of processing activities (Art. 30 GDPR) even as a solo practice.
• Data protection officer: mandatory if, as a rule, at least 20 people are permanently involved in the automated processing of personal data or a data protection impact assessment is required (§ 38 BDSG).
• Service providers: data processing agreements (Art. 28 GDPR) with your practice software, online appointment booking, hosting and IT support.
• Documentation: you keep patient records for at least ten years after the end of treatment (§ 630f Abs. 3 BGB).
• Telematikinfrastruktur: practices with statutory insurance approval are connected to the TI (e-prescription, electronic sick note, electronic patient record). Providers of therapeutic services must be connected by 1 October 2027; from 1 January 2027, Heilmittel are prescribed electronically (§ 360 SGB V).

Go online early

Most patients look for their practice online, and privately insured patients and self-payers even more so. Start three to six months before opening:

• Domain and email: a short domain that is easy to spell and an address such as praxis@ihre-praxis.de.
• Website: what patients look for is covered in 12 things for your practice website; what it costs, in the cost comparison.
• Impressum and mandatory information: the requirements differ by profession – for doctors, physiotherapists, psychologists and psychotherapists. The legal notice generator creates the text.
• Advertising: what is allowed is governed by the professional code and the Heilmittelwerbegesetz (Healthcare Advertising Act) – see the posts for doctors, physiotherapy, psychology and psychotherapy.
• Google profile: create and verify it as soon as your address is fixed – step by step in the post on the Google profile.

The checklist to tick off