Respiratory Therapists Application

Independent RT Provider Application - Cardiopulmonary

Personal Information

Please provide your contact and identification information.

Legal Name (Individual or Business Entity)

Email Address

Phone Number

Mailing Address

City

State

Zip Code

Social Security Number or EIN

Licensure & Credentials

Please provide your Florida RT license and certification information.

Florida RT License Number

License Expiration Date

Credential Type

CRT (Certified Respiratory Therapist)

RRT (Registered Respiratory Therapist)

NBRC Credential Number (if applicable)

Specialty Certifications (check all that apply)

NPS (Neonatal/Pediatric Specialist)

ACCS (Adult Critical Care Specialist)

RPFT (Registered Pulmonary Function Technologist)

SDS (Sleep Disorders Specialist)

CPFT (Certified Pulmonary Function Technologist)

Other

Professional Experience

Tell us about your respiratory therapy experience and areas of expertise.

Years of RT Experience

Less than 1 year

1-2 years

3-5 years

6-10 years

11-15 years

16-20 years

20+ years

Clinical Specialties/Areas of Expertise (check all that apply)

Adult Critical Care/ICU

Neonatal/Pediatric Critical Care

Emergency Department

Medical/Surgical Floor

Pulmonary Function Testing

Sleep Studies

Home Care/DME

Pulmonary Rehabilitation

Transport

Other

Additional Experience or Skills

Availability & Work Preferences

Please indicate your availability and preferred work arrangements.

Shift Availability (check all that apply)

Day Shift (7am-7pm)

Night Shift (7pm-7am)

Weekends

PRN/As Needed

Geographic Areas of Interest (check all that apply)

South Florida (Miami-Dade, Broward, Palm Beach)

Central Florida (Orange, Seminole, Osceola, Lake)

Tampa Bay Area (Hillsborough, Pinellas, Pasco)

Southwest Florida (Lee, Collier, Charlotte, Sarasota)

North Florida (Duval, St. Johns, Clay)

Panhandle (Escambia, Santa Rosa, Okaloosa)

Other Florida Areas

Earliest Available Start Date

Professional Liability Insurance & References

Please provide information about your professional liability insurance and professional references.

Do you currently have professional liability insurance?

Yes

No (I understand I may be required to obtain coverage)

Insurance Carrier (if applicable)

Policy Number (if applicable)

Professional Reference #1 - Name

Professional Reference #1 - Title

Professional Reference #1 - Phone

Professional Reference #2 - Name

Professional Reference #2 - Title

Professional Reference #2 - Phone

Independent Contractor Status Acknowledgment

Please carefully review and acknowledge the following statements regarding your independent contractor relationship with Cardiopulmonary.

Relationship Classification

I acknowledge that I am an independent contractor (1099), not an employee, and will not be treated as an employee for tax or any other purpose

I do not agree

Control & Autonomy

I acknowledge that I retain control over how services are performed, subject to applicable client standards and regulatory requirements

I do not agree

Taxes, Insurance, and Expenses

Financial Responsibility Acknowledgments (check all to confirm)

I am responsible for all federal, state, and local taxes, including self-employment tax, and will receive a 1099 form

I am not eligible for employee benefits including health insurance, retirement plans, paid time off, or unemployment benefits

I am responsible for my own professional liability insurance unless otherwise agreed in writing

I am responsible for my own tools, equipment, travel, and business expenses unless otherwise stated in a specific assignment agreement

Licensure, Compliance, and Conduct

Compliance Acknowledgments (check all to confirm)

I will maintain an active Florida RT license in good standing throughout the duration of any assignments

I will comply with all applicable federal, state, and local laws, regulations, and client facility policies

I will protect patient privacy and comply with HIPAA requirements and all applicable confidentiality obligations

I will immediately report any license action, sanction, exclusion from federal healthcare programs, or criminal charges

I will complete all required continuing education to maintain my Florida RT license, including medical errors prevention and laws/rules courses

Non-Exclusivity & Assignment Understanding

Non-Exclusivity

I understand this relationship is non-exclusive and I may contract with other organizations and maintain other employment

I do not agree

No Guarantee of Assignments

I understand there is no guarantee of assignments, minimum hours, or ongoing work, and I may accept or decline any assignment offered

I do not agree

Right to Accept or Decline Work

I understand I have the right to accept or decline any assignment without penalty or adverse consequence

I do not agree

Background Information

Have you ever been convicted of a felony or misdemeanor (excluding minor traffic violations)?

Yes

Criminal History Details (if applicable)

Has your RT license or any professional license ever been subject to disciplinary action, suspension, or revocation?

Yes

License Discipline Details (if applicable)

Are you currently excluded from participation in any federal healthcare programs (Medicare, Medicaid, etc.)?

Yes

Electronic Signature & Certification

By signing below, I certify that all information provided in this application is true, accurate, and complete to the best of my knowledge. I understand that any false statements or omissions may result in rejection of this application or termination of any independent contractor relationship.

Electronic Signature (Type Full Legal Name)

Date Signed