Hsmv Form 72190 - Medical Reporting Form
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1
2STATE OF FLORIDA
DEPARTMENT OF HIGHWAY SAFETY
AND MOTOR VEHICLES
DIVISION OF MOTORIST SERVICES
Medical Reporting Form
Section 322.126 (2), (3), Florida Statutes, provides that “Any physician, person, or agency
having knowledge of any licensed driver’s or applicant’s mental or physical disability to
drive…is authorized to report such knowledge to the Department of Highway Safety and Motor
Vehicles… The reports authorized by this section shall be confidential… No civil or criminal
action may be brought against any physician, person or agency who provides the information
herein.”
When reporting an individual whose driving ability is questionable due to some physical or
mental impairment, please complete as much of the information listed below as possible:
Name:
Date of Birth:
Address:
City:
Male
Female
Zip Code:
Driver License Number:
State:
Physical or Mental Disability Noted:
Seizures
Severe Cardiac Condition
Stroke
Loss of Consciousness
Uncontrollable Diabetes
Dementia/Memory Defects
Psychiatric Disturbance
Drug/Alcohol Addiction
Severe Visual Defect
Sleep Disorder
Other
Please describe:
Please indicate how you know this individual (friend, family member, patient, etc):
HSMV Form 72190 (Rev 07/13)
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Parent category: Legal