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Florida form 72190 2026

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  1. Click ‘Get Form’ to open it in the editor.
  2. Begin by entering the individual's name and date of birth in the designated fields. Ensure accuracy as this information is crucial for identification.
  3. Fill in the address, city, and zip code. Select the gender by checking either 'Male' or 'Female'.
  4. Input the driver's license number and state. This helps link the report to the correct individual.
  5. Mark any physical or mental deficits observed from the provided list. If applicable, explain each area marked in the space provided.
  6. Indicate your relationship to the individual being reported (e.g., friend, family member). This context can be important for review purposes.
  7. Complete your information as the reporting person, including name, agency (if applicable), and signature. Ensure all required fields are filled out before submission.
  8. Finally, mail the completed form to the Bureau of Motorist Compliance at the address provided on the form.

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Related links

MEDICAL REFERRAL FORM

HSMV 72190 (Effective 07/18), 15A-5.002, F.A.C.. STATE OF FLORIDA DEPARTMENT OF HIGHWAY SAFETY AND. MOTOR VEHICLES. MEDICAL REFERRAL FORM. Our agency isRead more

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Fla. Admin. Code Ann. R. 15A-5.002 - Report of Deficit or

This information may be submitted on a Medical Referral Form, HSMV 72190, Copies of the forms are available on the Departments website.

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