Hsmv Form 72190 PDF Details

In the State of Florida, maintaining the safety and well-being of the driving public is a paramount concern. In line with this commitment, the Florida Department of Highway Safety and Motor Vehicles (DHSMV) employs a comprehensive approach to identifying drivers who may present a safety risk due to physical or mental disabilities. The HSMV 72190 form, a critical tool in this process, facilitates the reporting of individuals whose ability to drive safely is questionable because of a medical condition. Enshrined within Section 322.126 (2), (3) of the Florida Statutes, the form allows physicians, persons, or agencies aware of a driver's or applicant's impairment to confidentially report their concerns to the DHSMV. Covering a wide array of conditions from seizures, severe cardiac situations, and dementia to sleep disorders and substance addiction, the form seeks detailed information about the individual's health status. Furthermore, the legislated protection against any civil or criminal liability for reporters underscores the form's role in promoting public safety over potential privacy concerns. Thus, the HSMV 72190 form stands as a testament to Florida's proactive measures in ensuring the roads are safe for all by systematically addressing the risks posed by medically impaired drivers.

QuestionAnswer
Form NameHsmv Form 72190
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesflorida dmv medical forms, florida dmv medical review form, medical form florida, hsmv 72190 form

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STATE 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)

Page 1 of 2

Please 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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