Hsmv Form 72190 - Medical Reporting Form Page 2
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1
2Please provide your information:
Date of Report:
Name:
Signature
Address:
City:
Zip:
Telephone:
Name of Law Enforcement Agency or Health Care Provider (if applicable):_________________
Law Enforcement ID/Badge# or Medical License# (if applicable): _______________________
Note: The name and signature of the reporting person is required to investigate the report.
Mail this completed form to:
Division of Motorist Services
Attn: Medical Review Section
Neil Kirkman building, MS 86
Tallahassee, Florida 32399-0500
Fax
(850) 617-3944
Telephone
(850) 617-3814
HSMV Form 72190 (Rev 07/13)
Page 2 of 2
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Parent category: Legal