Fill in Your Dopl Ap 078 Utah Form

The Dopl Ap 078 form is an essential document for individuals seeking licensure as a Physician Assistant in Utah. This form is designed to collect comprehensive information about the applicant, including personal details such as full legal name, Social Security number, and citizenship status. Applicants must confirm their qualifications by certifying that all information provided is accurate and complete. The form also outlines the various application fees associated with different licensure types, including a non-refundable fee for the Physician Assistant license and additional fees for controlled substances and temporary licenses. Furthermore, applicants are required to disclose any prior licenses or certifications held in other states, ensuring a thorough evaluation of their professional background. A section dedicated to professional experience allows candidates to detail their employment history since graduation from PA school, while another section focuses on the supervisory relationship with a physician in Utah. This includes the completion of a "Delegation of Services Agreement," which defines the working relationship and responsibilities between the Physician Assistant and their supervising physician. Overall, the Dopl Ap 078 form plays a crucial role in maintaining the standards of practice for Physician Assistants in Utah, ensuring that all applicants meet the necessary qualifications and comply with state regulations.