Florida’s medical referral form, HSMV 72190, is how anyone can alert the state that a licensed driver’s physical or mental condition may make them unsafe on the road. A physician, a police officer, another agency, a family member, or any concerned person can complete it and send it to the Florida Department of Highway Safety and Motor Vehicles (FLHSMV) Medical Review Program by fax at (850) 617-3944 or by mail to the Bureau of Motorist Compliance, Medical Review Program, Neil Kirkman Building, MS 86, Tallahassee, Florida 32399-0500.1Florida Department of Highway Safety and Motor Vehicles. Florida Statutes 322.126 – Medical Referral Form Once received, the referral can trigger a confidential review that ends in no action, license restrictions, retesting, suspension, or revocation.
Who Can File
Florida Statute 322.126 lets a wide range of people submit a referral: a physician, a law enforcement officer, another state agency, a family member, or any concerned citizen. You do not need to be the driver’s doctor or have any formal relationship with them. A good-faith belief that the person’s condition affects their ability to drive safely is enough.2The Florida Legislature. Florida Code 322.126 – Report of Disability to Department; Content; Use
Your Confidentiality as the Reporter
This is what stops most people from filing, so it is worth reading closely. Under Section 322.126, no civil or criminal action can be brought against anyone who submits information in good faith. The report itself is confidential, exempt from Florida’s public records law, and cannot be introduced as evidence in any civil or criminal trial.2The Florida Legislature. Florida Code 322.126 – Report of Disability to Department; Content; Use
The driver will not receive a copy of your report, and your identity stays sealed inside the department. The information also cannot be shared with insurers, employers, or other third parties for unrelated purposes.2The Florida Legislature. Florida Code 322.126 – Report of Disability to Department; Content; Use
How to Fill Out HSMV 72190
Download the form as a PDF from the FLHSMV website. A Spanish version, HSMV 72190 SP, is also available.3Legal Information Institute. Florida Administrative Code Annotated R 15A-5.002 – Report of Deficit or Disorder to the Department It is one page with three parts: driver information, a condition checklist, and a written explanation.
Driver Information
Fill in as much as you know: full name, date of birth, address, gender, zip code, state, and driver license number.1Florida Department of Highway Safety and Motor Vehicles. Florida Statutes 322.126 – Medical Referral Form At minimum, the department needs the driver’s name and either their date of birth or license number to match the referral to the right record. If you do not have the license number, provide whatever else helps narrow the search, such as address or vehicle description.
Condition Checklist
Check every box that applies. The form lists these categories:1Florida Department of Highway Safety and Motor Vehicles. Florida Statutes 322.126 – Medical Referral Form
- Seizures
- Severe cardiac condition
- Stroke
- Loss of consciousness
- Uncontrollable diabetes
- Dementia / memory deficits
- Psychiatric disturbance
- Drug / alcohol addiction
- Severe visual deficit
- Sleep disorder
- Other
The form itself notes that reviews are opened based on conditions affecting safe vehicle operation, not on the driver’s age.1Florida Department of Highway Safety and Motor Vehicles. Florida Statutes 322.126 – Medical Referral Form
Written Explanation
The explanation section is where the referral either goes somewhere or dies on the desk. The department evaluates actual evidence of risk rather than medical diagnoses, so stick to what you have personally seen: dates, specific behaviors, and how often they happen. Running red lights, drifting between lanes, getting lost on familiar routes, not remembering a recent trip. A family member describing a parent’s repeated confusion behind the wheel carries real weight without any clinical terminology.
Vague language is the main reason referrals go nowhere. “Seems confused sometimes” gives the department nothing to act on. “On three occasions in January and February 2026, drove the wrong way down a one-way street near home and could not recall doing so afterward” gives them a basis for opening a review.
Where to Send the Form
Send the completed form to the FLHSMV Medical Review Program by one of two methods:1Florida Department of Highway Safety and Motor Vehicles. Florida Statutes 322.126 – Medical Referral Form
- Fax: (850) 617-3944
- Mail: Bureau of Motorist Compliance, Medical Review Program, Neil Kirkman Building, MS 86, Tallahassee, Florida 32399-0500
Faxing is faster and generates a transmission confirmation. If you mail the form, certified mail gives you a receipt. Keep a copy either way. The Medical Review Section’s phone number for follow-up is (850) 617-3814.4Florida Department of Highway Safety and Motor Vehicles. Medical Review Contact Us
What Happens After You File
Staff first decide whether the referral warrants a formal investigation. If the complaint looks questionable, they may look into its validity before going further.5Florida Department of Highway Safety and Motor Vehicles. The Medical Review Process
If a review opens, the driver receives written notice that they are under medical review and has 45 days to submit medical information from their physician. The driver pays for their own evaluation; Florida statute specifies medical reports must be submitted without expense to the state. A driver who ignores the notice or refuses to submit documentation can have their license suspended or revoked on that basis alone.6The Florida Legislature. Florida Code 322.221 – Department May Require Reexamination
Once the driver’s medical information comes in, the department forwards it to Florida’s Medical Advisory Board. The board applies condition-specific standards in Florida Administrative Code Chapter 15A-5, which has separate sections for seizures, loss of consciousness, cardiovascular conditions, and the other checklist categories.7Justia. Florida Administrative Code 15A-5 – Medical Advisory Board Guidelines Florida law requires the FLHSMV to make its decision within 90 days of receiving all requested medical information from the driver.5Florida Department of Highway Safety and Motor Vehicles. The Medical Review Process
Possible Outcomes
After the review, the department can:6The Florida Legislature. Florida Code 322.221 – Department May Require Reexamination
- Take no action and leave the license unchanged.
- Issue a restricted license with conditions such as daytime-only driving, no highway driving, corrective lenses, or periodic medical follow-ups.
- Require a vision test, knowledge test, or driving skills test before continuing the license.
- Suspend or revoke the license if the condition poses a clear safety risk.
The driver is notified of the outcome in writing and, if suspended or revoked, can request an administrative hearing under Section 322.271.
Reinstatement Is Possible
A medical suspension is not always permanent. If the driver’s condition improves or is brought under control, they can work toward reinstatement. The Medical Review Board sends a decision letter that the driver takes to their local driver license office to complete the process, and depending on the board’s requirements they may need to pass one or more tests, submit updated medical documentation, or both.5Florida Department of Highway Safety and Motor Vehicles. The Medical Review Process
Follow-up reports are common as an ongoing condition of licensure. A driver cleared after a seizure disorder review, for example, may have to submit periodic physician reports confirming they remain seizure-free. Missing one of those follow-ups puts the license back in jeopardy.
Commercial Drivers
If the driver you are reporting holds a commercial driver’s license, the state medical review sits on top of a separate federal medical certification requirement, and any Florida restriction or suspension can also trigger a downgrade of CDL privileges. Federal rules require states to post each driver’s medical status and certificate expiration date to the Commercial Driver’s License Information System, so a Florida medical flag follows the driver nationally.8Federal Motor Carrier Safety Administration. Medical The referral form and process are the same; the downstream consequences reach further.