How to Fill Out and Submit Florida’s DMV Vision Form (HSMV 72119)

Florida’s DMV vision form HSMV 72119 is the one-page document a licensed doctor or optometrist uses to record your distant visual acuity so you can renew your driver license at age 80 or older without taking the screening in person. You fill in the top half, the physician fills in the bottom half and signs it, and the results are then sent to the Department of Highway Safety and Motor Vehicles. The exam is valid for one year from the date it was performed, so don’t schedule it far in advance of your renewal.

Who Needs This Form

Florida Statute 322.18(5) requires every licensee who is at least 80 years old to pass a vision test as part of the six-year renewal cycle. There are two ways to satisfy that requirement, and only one of them uses HSMV 72119.

If you renew in person at a driver license service center or a participating county tax collector office, staff screen your eyes on the spot at no extra charge. No form is needed.

If you want to renew online or by mail, a licensed medical doctor, osteopathic physician, optometrist, or physician at a federally established veterans’ hospital has to administer the test, record it on HSMV 72119, and submit the results electronically to the department before the renewal can be processed. Florida law prohibits processing a convenience-service renewal for anyone 80 or older until those results are on file.¹

How to Fill Out HSMV 72119

You can download the form from the FLHSMV website or pick up a copy at a driver license service center.² It has a patient section at the top and a physician section below.

Patient Section

Print your doctor’s full name on the authorization line at the top. That line authorizes that specific practitioner to examine your eyes and send the results to the Division of Motorist Services. Then sign your name, enter your Florida driver license number, and write your current mailing address with city, state, and ZIP code. Sign this section in the doctor’s presence; the physician certification below states that you did.³

Physician Section

Your doctor completes the certification confirming they are licensed under Chapter 458 (medical doctors), Chapter 459 (osteopathic physicians), or Chapter 463 (optometrists) of the Florida Statutes, or that they practice at a federally established veterans’ hospital. They print your name and date of birth, and record their medical license number, signature, exam date, business address, and phone number.

Below the certification is the vision examination grid. The doctor records your distant visual acuity in three columns (right eye, left eye, both eyes) across two rows (uncorrected and with best correction). Each entry is a Snellen fraction such as 20/40. Only distant vision is recorded; there is no near-vision section on this form.³

The Vision Standards Your Results Are Measured Against

Florida Administrative Code Rule 15A-1.013 sets the thresholds the department applies to what the doctor writes down:

Better than 20/40 in both eyes, with or without corrective lenses: you pass outright.
Worse than 20/40 in either eye: referred to a licensed eye specialist to see if vision can be improved.
20/70 in either eye that cannot be improved: you can still qualify, but if one eye is blind or 20/200 or worse, the other must be 20/40 or better.
20/80 or worse in both eyes that cannot be improved: a license will not be issued.

The minimum acceptable field of vision is 130 degrees. Florida does not recognize telescopic or bioptic lenses for the purpose of meeting these standards or passing the vision test.⁴³

When Your Doctor Should Use HSMV 72010 Instead

HSMV 72119 is for straightforward cases only. A note on the form directs the physician to switch to the Report of Eye Examination (HSMV 72010) if either of these applies:

Your visual acuity is 20/50 or worse in either eye, with or without corrective lenses.
There is any indication of eye disease or injury that could affect your ability to drive.

HSMV 72010 captures additional clinical detail the department needs for a medical review of your driving eligibility.³

How to Submit the Completed Form

How you submit depends on how you plan to renew.

Electronic Submission by Your Doctor

For an online or mail renewal, the physician or optometrist must submit your results electronically through a department-approved method before you complete the renewal. The department will not process the renewal for a driver 80 or older until those results are already in the system.¹ Ask the doctor’s office whether they can submit electronically to FLHSMV before you schedule the appointment.

In Person

You can also bring the completed paper form to any Florida driver license service center or participating county tax collector’s office. Staff will review it, verify it’s complete and dated within the past year, and process your renewal on the spot. This is the simplest path if your doctor’s office isn’t set up for electronic submission.

By Mail

If your renewal notice says you’re eligible to renew by mail, send the completed form with your renewal materials to:

Division of Motorist Services
2900 Apalachee Parkway, MS92
Tallahassee, FL 32399

The form must arrive before your current license expires, and mailed renewals take longer to process than in-person visits. Your new license goes to the address on file once processing is complete.

What Happens If You Don’t Pass

If your vision falls below the state’s minimum standards and cannot be corrected, the department will deny the renewal. Anyone 80 or older whose driving privilege is denied because of a failed vision test receives a state identification card at no charge.¹ In the borderline range (worse than 20/40 but not 20/80 or worse in both eyes), you may still qualify for a restricted license after the medical review triggered by HSMV 72010.⁴

1
Florida Senate. Florida Statutes 322.18 – Original Applications, Licenses, and Renewals
2
Florida Department of Highway Safety and Motor Vehicles. Forms for Older Drivers
3
Florida Department of Highway Safety and Motor Vehicles. HSMV 72119 – Mature Driver Vision Test
4
Cornell Law Institute. Florida Administrative Code 15A-1.013 – Minimum Visual Standards for Licensing