Florida HSMV Form 72112 – Diabetes Follow-up Guide

What Is Florida HSMV Form 72112?

HSMV Form 72112 is a physician-completed follow-up form used by the Florida Department of Highway Safety and Motor Vehicles. It is specifically designed for drivers previously reviewed for an episode of hypoglycemia. The form gathers updated medical information so the department can reassess the individual’s ability to drive safely.

The form became effective in its current version on July 1, 2018 (HSMV 72112, Effective 07/18) and is incorporated by reference in Rule 15A-5.005, Florida Administrative Code, which addresses loss of consciousness related to medical conditions.

According to the rule, applicants or licensed drivers who may have experienced loss of consciousness due to hypoglycemia must provide a Medical Report (HSMV 72423) and/or the Diabetes/Hypoglycemia Follow-Up Form (HSMV 72112) from their treating physician.

When Is Form 72112 Required?

Form 72112 is typically requested in these situations:

• A driver has a documented history of hypoglycemia that previously triggered a medical review by FLHSMV.
• The department is conducting a follow-up evaluation to determine if the driver’s diabetes is adequately controlled.
• The driver is seeking reinstatement or continued licensure after a hypoglycemic episode that affected consciousness or driving ability.
• In some cases involving a motor vehicle crash related to hypoglycemia, additional forms such as HSMV 72118 (Diabetes Form) may also be required.

The Medical Review Program’s goal is not to automatically remove driving privileges but to ensure any medical condition does not interfere with the safe operation of a motor vehicle. Drivers usually receive written notice and must submit the completed medical forms within 45 days.

Key Questions on the Diabetes/Hypoglycemia Follow-up Form

The form is addressed to the treating physician and requests specific clinical information. The main questions include:

1. Treatment history: How long has the physician treated the patient, and when was the most recent office visit?
2. Further episodes: Has the patient experienced any additional episodes of hypoglycemia? If yes, the physician must provide dates and describe the severity of the reactions.
3. Diabetes control: What is the physician’s assessment of the control of the patient’s diabetes?
4. Prevention advice: What advice has the patient been given to prevent recurrence of hypoglycemia while driving?
5. Safety assessment: To the best of the physician’s knowledge, is the patient sufficiently well instructed and conscientiously applying these instructions so that it is highly unlikely they would have an episode of hypoglycemia while operating a motor vehicle? (Yes/No, with space for comments.)

The physician must also sign the form, print their name, provide their medical license number, address, telephone number, and the date of completion.

How to Complete and Submit Form 72112?

Follow these steps to properly submit the form:

1. Download the official PDF from the FLHSMV website: https://www.flhsmv.gov/pdf/forms/72112.pdf.
2. Take the form to the physician most familiar with your diabetes management and recent medical history.
3. Ensure the physician completes every section accurately and legibly.
4. The completed form must be mailed (or sometimes faxed) to the Medical Review Program.

Mailing address:
Bureau of Motorist Compliance
Medical Review Program
Neil Kirkman Building, MS 86
Tallahassee, Florida 32399-0500

Telephone: (850) 617-3814
Fax: (850) 617-3944

Drivers should keep a copy of the completed form for their records. FLHSMV is required by law to render a decision within 90 days after receiving all requested medical information.

Related Forms and the Medical Review Process

Form 72112 often works together with other medical documents:

• HSMV 72423 – Medical Report: A comprehensive form covering multiple medical conditions, including a dedicated diabetes section.
• HSMV 72118 – Diabetes Form: Required when a hypoglycemic episode resulted in a motor vehicle crash.
• HSMV 72117 – Loss of Consciousness Follow-up Form: Used for other causes of loss of consciousness.

The overall medical review process begins when FLHSMV receives a report from a physician, law enforcement, court, agency, or concerned citizen. After validation, the driver is notified in writing and asked to provide medical documentation. The Medical Advisory Board reviews the information and makes a recommendation. Possible outcomes include unrestricted approval, approval with conditions (such as periodic follow-up reports), re-examination, or denial/revocation of driving privileges if the condition poses a significant public safety risk.

For more details on the Medical Review Program, visit the official FLHSMV page: FLHSMV Medical Review.

Why Proper Completion Matters for Florida Drivers?

Accurate and timely submission of Form 72112 can help drivers maintain their driving privileges when their diabetes is well managed. Incomplete or late forms may delay the review process or result in temporary suspension of driving privileges until the required information is received.

Physicians play a critical role by providing an honest clinical assessment. The form specifically asks whether the patient is unlikely to experience hypoglycemia while driving, based on instruction and compliance.

Drivers with diabetes are encouraged to work closely with their healthcare providers on strategies that reduce the risk of hypoglycemia while operating a vehicle, such as regular blood glucose monitoring before driving, carrying fast-acting carbohydrates, and recognizing early warning signs.

Where to Find Official Resources?

• Official Form 72112 PDF: Download here
• FLHSMV Forms Directory: https://www.flhsmv.gov/resources/forms/
• Florida Administrative Code Rule 15A-5.005 (Loss of Consciousness): Available through the Florida Department of State rules database and legal reference sites.
• Medical Review Program contact: (850) 617-3814 or the address listed on the form.

Final Tips for Florida Drivers with Diabetes

If you receive a notice requiring Form 72112, act promptly. Contact your treating physician as soon as possible, bring the official form, and request that it be completed thoroughly. Keep copies of all correspondence with FLHSMV and your medical provider.

Managing diabetes effectively is the best way to support safe driving and a positive medical review outcome. Regular medical follow-up, adherence to treatment plans, and open communication with both your doctor and the FLHSMV Medical Review Program help protect both your driving privilege and public safety on Florida roads.