Blank Dopl Ap 078 Utah Form Create Your Dopl Ap 078 Utah

Blank Dopl Ap 078 Utah Form

The Dopl Ap 078 Utah form is a crucial document for individuals seeking licensure as a Physician Assistant in Utah. This form collects essential information about the applicant, including personal details, professional experience, and educational background. Completing this form accurately is vital for ensuring a smooth application process, so be sure to fill it out by clicking the button below.

Create Your Dopl Ap 078 Utah
Contents

Similar forms

  • Application for Licensure (DOPL-AP-001): This document serves as a general application for various professional licenses in Utah. Like the DOPL AP 078, it requires personal information, proof of qualifications, and an application fee.
  • Power of Attorney Form: When needing to delegate decision-making authority, utilize our essential Power of Attorney form resources to ensure proper legal documentation.
  • Controlled Substance License Application (DOPL-AP-002): Similar to the DOPL AP 078, this form specifically applies to individuals seeking to prescribe controlled substances. It also includes a fee and requires proof of identity and qualifications.
  • Temporary License Application (DOPL-AP-003): This application allows professionals to practice temporarily while awaiting their full license approval. Like the DOPL AP 078, it requires personal details and a fee.
  • License Renewal Application (DOPL-AP-004): This document is used for renewing existing licenses. It shares similarities with the DOPL AP 078 in that it requires personal information and proof of continued qualifications.
  • Change of Address Notification (DOPL-AP-005): This form is used to update the licensing agency about a change in address. It is similar to the DOPL AP 078 in that it requires personal information but is focused solely on address changes.
  • Continuing Education Reporting Form (DOPL-AP-006): This form is used to report completed continuing education credits. Like the DOPL AP 078, it emphasizes the importance of maintaining qualifications in the profession.
  • Verification of Licensure (DOPL-AP-007): This document is used to verify existing licenses with the state. It is similar to the DOPL AP 078 in that it requires the applicant's personal information and may involve a fee.

Your Questions, Answered

What is the Dopl Ap 078 Utah form used for?

The Dopl Ap 078 form is an application for individuals seeking licensure as a Physician Assistant in Utah. It includes sections for personal information, education, professional experience, and details about supervising physicians. This form is essential for those looking to practice as a Physician Assistant in the state.

What fees are associated with the Dopl Ap 078 form?

There are several non-refundable application fees associated with the Dopl Ap 078 form:

  • Physician Assistant: $180.00
  • Controlled Substance: $100.00
  • Physician Assistant Temporary: $50.00

Make sure to include the correct fee when submitting your application to avoid delays.

How do I complete the Dopl Ap 078 form?

You can fill out the form using Microsoft Word. After filling in the necessary information, print the form and keep a copy for your records. Ensure that you provide accurate information as it will be used for your application review.

What information do I need to provide on the form?

The form requires personal details such as:

  • Your full legal name
  • Social Security number
  • Mailing address
  • Date of birth
  • Phone number and email

Additionally, you must list any other licenses or certifications you hold, as well as your educational background and professional experience.

What if I am not currently practicing as a Physician Assistant in Utah?

If you are not practicing as a Physician Assistant in Utah, you must indicate this on the application. You will also need to agree to submit a “Notification of Change” form if you decide to practice in Utah in the future.

What is the Delegation of Services Agreement?

The Delegation of Services Agreement is a document that outlines the working relationship between you and your supervising physician. It includes details about supervision, prescribing controlled substances, and emergency procedures. This agreement must be completed and available at your practice sites.

What happens if my application is denied?

If your application is denied, you will receive a notification stating the reason for the denial. It is crucial to review the comments provided and address any issues before reapplying. Understanding the reasons for denial can help you strengthen your application in the future.

How can I contact the Division of Occupational & Professional Licensing?

You can reach the Division of Occupational & Professional Licensing by calling (801) 530-6628. For more information, visit their website at www.dopl.utah.gov. They can assist you with any questions related to the application process or requirements.

Key takeaways

When filling out the Dopl Ap 078 form in Utah, keep these key takeaways in mind:

  • Provide Accurate Information: Ensure that your full legal name matches your identification documents, such as your driver’s license or Social Security card.
  • Understand Application Fees: Be aware of the non-refundable application fees for different categories, such as $180 for a Physician Assistant license.
  • Document Verification: If you are a non-citizen, attach the necessary documentation to prove your legal presence in the United States.
  • Affidavit and Authorization: Sign the affidavit section to certify the truthfulness of your application and authorize the release of your records for evaluation.

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Dos and Don'ts

  • Do ensure your full legal name is listed exactly as it appears on your driver’s license or Social Security card.
  • Do provide accurate and complete information regarding your citizenship status and identification.
  • Do attach any required documentation, such as a passport or government-issued ID, if applicable.
  • Do double-check all entries for accuracy before submitting the form.
  • Do keep a copy of the completed form for your records.
  • Don't leave any required fields blank; incomplete applications may be denied.
  • Don't provide false information or omit material facts; this can lead to legal consequences.
  • Don't forget to sign and date the application; an unsigned application is invalid.
  • Don't submit the form without paying the required application fee.
  • Don't ignore the instructions regarding additional sheets for listing licenses or employment history.