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Medical Referral Form

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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