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Medical Referral Form

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HSMV form 72190 (Effective 07/18), , Page 1 of 2 STATE OF FLORIDA DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES Medical Referral form Our agency is committed to complying with the Americans with Disabilities Act (ADA), a federal law which makes it unlawful to discriminate against a qualified person with a disability. Medical reviews are initiated based on Medical conditions or symptoms that could affect the safe operation of a motor vehicle and not the age of the driver. Sections (2) and (3), Florida Statutes, provide, in part, 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.

HSMV Form 72190 (Effective 07/18), 15A-5.002, F.A.C. Page 1 of 2 . STATE OF FLORIDA . DEPARTMENT OF HIGHWAY SAFETY . AND MOTOR VEHICLES . Medical Referral Form . Our agency is committed to complying with the Americans with Disabilities Act (ADA), a federal law which makes it unlawful to discriminate against a qualified person with a disability.

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