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REQUIREMENTS/INFORMATION FOR LICENSE- RESPIRATORY THERAPIST

Access this form via website at: cca.hawaii.gov/pvl/programs/respiratory

DEFINITIONS No person shall practice as a respiratory therapist in this State unless the person is appropriately licensed.

"Licensed respiratory therapist" means a person who engages in the practice of respiratory care and uses the title

of licensed respiratory therapist; who has been issued a license pursuant to Chapter 466D, Hawaii Revised Statutes;

and whose license is in effect and not revoked, suspended, or encumbered. (Additional titles will be addressed in

the Respiratory Therapist rules).

"Practice of respiratory care" means providing assessment, therapy, management, rehabilitation, support services

for diagnostic evaluation, education, and care for patients with deficiencies and abnormalities that affect the

pulmonary system, including:

(1) Respiratory care services, including the administration of pharmacological, diagnostic, and

therapeutic care related to respiratory care procedures necessary for treatment, disease

prevention, rehabilitative, or diagnostic regimens prescribed by a physician;

(2) Observation and monitoring of signs, symptoms, reactions and physical responses to

respiratory care treatment and diagnostic testing;

(3) Diagnostic or therapeutic use of:

(A) Medical gases, excluding general anesthesia;

(B) Aerosols, humidification, environmental control systems, or invasive and

non-invasive modalities;

(D) Mechanical or physiological ventilatory support, including maintenance of

natural airways and insertion and maintenance of artificial airways;

(E) Cardiopulmonary resuscitation; and

(F) Respiratory protocol and evaluation or diagnostic and testing techniques

required for implementation of respiratory care protocols; and

(Additional clarification will be addressed in the Respiratory Therapist rules).

(4) The transcription and implementation of the written, verbal, and telecommunicated orders of

a physician pertaining to the practice of respiratory care.

APPLICATION

FORM

Complete the on-line application form or print legibly in black ink. Sign and date the form. Submit with required

documents and fees. Failure to provide all requested information will delay the processing of your application.

Applicants are subject to meet all requirements in effect at the time of filing.

REQUIREMENTS The following information must be provided on the application:

• National Certification - Each applicant is required to have passed the Certified Respiratory Therapist

Examination (CRT) or Registered Respiratory Therapist Examination (RRT) of the National Board for

Respiratory Care (NBRC). You may either attach the NBRC official verification letter to your application

(this is preferable to us) or you may request the NBRC to mail us your verification.

To obtain your verification information, please visit the NBRC website at: www.nbrc.org and click on

credentialed practitioners.

Phone No.: (913) 895-4900 Fax No.: (913) 895-4650

RT-00 0421R

(CONTINUED ON PAGE 2)

(OPTIONAL)

ENDORSEMENT

OF LICENSES IN

ANOTHER STATE

OR JURISDICTION

A license through endorsement may be granted to applicants who hold CURRENT licenses in another state or

jurisdiction that are in good standing, provided that the program's requirements, at the time you were

licensed in that state, are equivalent or higher than Hawaii's.

In addition to the application and fee, you must:

Request a "Verification of License - Respiratory Therapist form (Form RT- 05) be completed by the states where you

are licensed and attach original with board's seal to your application form, or you may have them send it directly to

Hawaii. Complete the "Applicant Section" and send the form to your out-of-state agency.

NOTE: Some states charge a fee for this service. Contact your out-of-state agency for fee information.

SOCIAL

SECURITY

NUMBER

Your Social Security Number is used to verify your identity for licensure purposes and for compliance with the laws

mentioned below. For a license to be issued you must provide your Social Security Number or your application

will be deemed deficient and will not be processed further. The following laws require that you furnish your Social

Security Number to our agency:

FEDERAL LAWS:

42 U.S.C.A. §666 (a)(13) requires the Social Security Number of any applicant for a professional license or

occupational license be recorded on the application for license; and if you are a licensed health care practitioner,

45 C.F.R., Part 61, Subpart B, §61.7 requires the Social Security Number as part of the mandatory reporting we

must do to the Healthcare Integrity and Protection Data Bank, of any final adverse licensing action against a

licensed health care practitioner.

HAWAII REVISED STATUTES ("HRS"):

§576D-13(j), HRS requires the Social Security Number of any applicant for a professional license or occupational

license be recorded on the application for license; and §436B-10(4), HRS which states that an applicant for license

shall provide the applicant's Social Security Number if the licensing authority is authorized by federal law to

require the disclosure (and by the federal cites shown above, we are authorized to require the Social Security

Number).

APPLICATION Complete the attached application and submit with copies of the aforementioned "Requirements" and fees to:

Mailing address:

Respiratory Therapists Program

DCCA-PVL Licensing Branch

P.O. Box 3469

Honolulu, HI 96801

Walk-in address:

335 Merchant Street

Room 301

Honolulu, HI 96813

Phone No. (808) 586-3000

FEES ATTACH the appropriate fees. Make check or money order payable to: Commerce and Consumer Affairs. (check

must be in U.S. dollars and be from a U.S. financial institution.)

If applying for licensure between July 1 and June 30 of the first year of the triennium, (2020, 2023, 2026),

pay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $340

(Appl fee - $60* + License fee - $50 + CRF - $150 + 2/3 renewal - $80)

If applying for licensure between July 1 and June 30 of the second year of the triennium, (2021, 2024. 2027),

pay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $250

(Appl fee - $60* + License fee - $50 + CRF - $100 + 1/3 renewal - $40)

If applying for licensure between July 1 and June 30 of the third year of the triennium, (2022, 2025, 2028),

pay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $160**

(Appl fee - $60* + License fee - $50 + CRF - $50)

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(CONTINUED ON PAGE 3)

*Application fee is non-refundable.

**SUBJECT TO RENEWAL BY JUNE 30 EVERY THREE YEARS (2023, 2026, 2029), REGARDLESS OF ISSUE DATE.

In addition to the education and examination requirements, an applicant shall be beyond the age of majority

(18 years of age) a United States citizen, a United States national, or an alien authorized to work in the United

States. If you are not a citizen or national of the United States or alien authorized to work in the United States your

application may be denied. Reforms in the immigration laws of the United States have led to new requirements

for aliens who seek to enter the United States for the purpose of performing labor as a health-care worker,

including respiratory therapists. Federal law mandates that any such alien is inadmissible from the country unless

the alien presents a certificate from an independent credentialing organization approved by the Attorney General

(See U.S.C. 1182(a)(5)).

AGE OF MAJORITY

AND U.S. CITIZEN

LAWS It is the responsibility of the respiratory therapist to know and comply with the laws pertaining to the practice of

respiratory therapy. To obtain a copy of the Respiratory Therapists law, Chapter 466D, Hawaii Revised Statutes,

visit our website at cca.hawaii.gov/pvl/programs/respiratory, then click on "Statute/Rule" on the right. Chapter

436B, Hawaii Revised Statutes, the Professional and Vocational Licensing Act, should be read in conjunction with

Chapter 466D.

ABANDONED

APPLICATIONS

Pursuant to HRS §436B-9, your application shall be considered abandoned and shall be destroyed if you fail to

provide evidence of continued efforts to complete the licensing process for two consecutive years. The failure to

provide evidence of continued efforts include, but is not limited to: (1) failure to submit any required information

and documents requested by the licensing authority within two consecutive years from the last date the

documents and information were requested, or (2) failure to complete any additional requirements for licensure

that remain after approval of your application, or (3) failure to provide the licensing authority with any written

communication during two consecutive years indicating that you are attempting to complete the licensing

process. If an application is deemed abandoned, the applicant shall be required to reapply for licensure and

comply with the licensing requirements in effect at the time of the reapplication.

-3-

This material can be made available for individuals with special needs. Please call the Licensing Branch Manager at (808) 586-3000 to submit your request.

All respiratory therapist licenses, regardless of issuance date, shall be renewed triennially (every three years) on or

before June 30, with the first renewal occurring on July 1, 2014. Failure to renew a license shall result in the

forfeiture of the license. A forfeited license may be restored within one year from the expiration date upon

payment of the renewal and restoration fees, including any penalty or delinquent fees. Failure to restore a

forfeited license within one year shall result in the automatic termination of the license. A person whose license

has been terminated shall be required to reapply for a new license as a new applicant. A person whose license has

been forfeited may not practice as a respiratory therapist until the license has been restored.

TRIENNIAL

RENEWAL

If an agency or individual is assisting you with the licensure process, we will not be able to release any information

to them unless you provide us with authorization. If you wish to do so, please complete the portion on Release of

Information to Third Party, sign and date it.

RELEASE OF

INFORMATION

LICENSE

DENIAL

If for any reason you are denied the license you are applying for, you may be entitled to a hearing as provided by

Title 16, Chapter 201, Hawaii Administrative Rules, and/or Chapter 91, Hawaii Revised Statutes.

NOTE: One of the numerous legal requirements that you must meet in order for your new license to be issued is the

payment of fees as set forth in this application. You may be sent a license certificate before the payment you sent us for

your required fees is honored by your bank. If your payment is dishonored, you will have failed to pay the required

licensing fee and your license will not be valid, and you may not do business under that license. Also, a $25.00 service

charge shall be assessed for payments that are dishonored for any reason.

FEES (cont.)

Print Form

APPLICATION FOR LICENSE - RESPIRATORY THERAPIST

Access this form via website at: cca.hawaii.gov/pvl/programs/respiratory

Read the Requirements/Information page before completing this form.

Type or print legibly in black ink.

CHECK ONE: New License License by endorsement

Legal Name (First, Middle) (Last)

Residence Address (Include Apt. No., City, State & Zip Code)

Mailing Address (ONLY if different from above)

FOR OFFICE USE ONLY

Initials/Date:

Approved

Lic. No.

RT -

Eff. Date:

Other Names Used (include maiden name):

Social Security No.

Phone No. (days)

( )

NATIONAL

CREDENTIALS

I hold the following credential(s) issued by the National Board for Respiratory Care (NBRC):

STATE LICENSES

Name of State (Attach additional sheets if needed) License Number Date Issued License current?

Please have verification of your respiratory therapist license from the licensing authority of each state in which you hold or held

a license at any time sent directly to our department or attach the original verification to your application form.

Please check your answer to the following questions as it pertains to the individual applying for a respiratory therapist license:

1. Are you at least 18 years of age? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes No

2. Are you a U.S. citizen, a U.S. national, or an alien authorized to work in the United States? . . . . . . . . . . . . . . .

Yes No

3. Have you taken and passed the CRT or RRT Examination? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes No

If "YES", provide passage date:

4. Have you ever been denied a registration, certificate, or license to practice respiratory care? . . . . . . . . . . . .

Yes No

5. Has any license, recognition, authority, registration or national credentials ever been revoked,

suspended, encumbered or otherwise subject to disciplinary action? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes No

6. Are you presently being investigated or is any disciplinary action pending against your license,

recognition, authority or registration in this State or any other jurisdiction? . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes No

7. Have you ever been convicted of a crime in any jurisdiction that has not been annulled or

expunged? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes No

If you answered "yes" to questions 4, 5 ,6, or 7, please provide a detailed signed statement and certified copies of documents

pertaining to the prior or pending disciplinary action(s) or conviction(s).

Appl . . . . . . . . . . . . . . . 850 . . . . . . . . . . . . . . . . $60 CRF . . . . . . . . . . . . . . . . 853 . . . . . . . . . . . . . . . . $150/$100/$50

Lic . . . . . . . . . . . . . . . . . 851 . . . . . . . . . . . . . . . . $50 Renewal . . . . . . . . . . . 858 . . . . . . . . . . . . . . . . $80/$40

Service Charge . . . . . BCF . . . . . . . . . . . . . . . . $25

RT-01 0421R

(CONTINUED ON PAGE 2)

RT Checklist

National

Certification

Lic. Verification:

Fees $340/$250/$160

Date of Birth

Certified Respiratory Therapist (CRT) No./Issue Date: Registered Respiratory Therapist (RRT) Registry No./Issue Date:

CRT No.:

Issue Date:

Provide date you requested CRT:

RRT Registry No.:

Issue Date:

Provide date you requested RRT:

Print Name of Applicant: Date:

AFFIDAVIT OF APPLICANT:

I hereby certify that the statements, answers, and representations made in this application and in the documents

attached are true and correct. I understand that any misrepresentation is grounds for refusal to grant or subsequent

revocation of license and is a misdemeanor (Section 710-1017, Sections 436B-19, and 466D-11, Hawaii Revised Statutes.)

I further certify that I have read and will abide by the provisions of Hawaii Revised Statutes, Chapters 466D and

436B and the Hawaii Administrative Rules when they are promulgated.

DateSignature of Applicant

-2-

This material can be made available for individuals with special needs. Please call the Licensing Branch Manager at (808) 586-3000 to submit your request.

Release of Information to Third Party:

To assist me in the licensing process, I authorize DCCA's staff to release any and all information regarding my application

(including, but not limited to application status) to the following third party:

Print Name of Individual who is assisting you:

Name of Organization:

Signature of Applicant Date

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