Florida HSMV Form 72117 Loss of Consciousness Follow-up – The Florida Department of Highway Safety and Motor Vehicles (FLHSMV) uses specialized medical forms to evaluate whether drivers with certain health conditions can safely operate a motor vehicle. One of the most important documents in this process is HSMV Form 72117, officially titled the Loss of Consciousness Follow-up Form.
This form plays a critical role in Florida’s Medical Review Program. It allows treating physicians to provide updated medical information about drivers who previously experienced a loss of consciousness, helping the department’s Medical Advisory Board determine ongoing fitness to drive.
Download the official form here:
Florida HSMV Form 72117 – Loss of Consciousness Follow-up Form (PDF)
What Is Florida HSMV Form 72117?
HSMV Form 72117 is an official Florida document used exclusively for follow-up medical evaluations related to loss of consciousness (also called syncope, blackouts, or episodes of unconsciousness). The form is referenced in Florida Administrative Code Rule 15A-5.005 and became effective in its current version on July 18, 2018.
Unlike the initial Medical Report (HSMV 72423), Form 72117 is specifically designed for drivers who have already undergone review for a previous loss-of-consciousness event. The FLHSMV sends this form (or requests its completion) when reassessing a driver’s ability to safely operate a motor vehicle.
The form is completed by the driver’s treating physician and returned directly to the Bureau of Motorist Compliance’s Medical Review Program.
Who Needs to Complete Form 72117?
This form is typically required in the following situations:
- A Florida driver or license applicant previously experienced a loss of consciousness and is under medical review.
- The Medical Advisory Board or FLHSMV Medical Review Program requests updated information to reassess driving privileges.
- A physician is asked to provide a professional opinion on whether the patient can safely continue driving after a prior episode.
Note that loss of consciousness caused by hypoglycemia (low blood sugar) may instead require the Diabetes/Hypoglycemia Follow-up Form (HSMV 72112) or the Diabetes Form (HSMV 72118) if a crash was involved.
Purpose of the Loss of Consciousness Follow-up Form
The primary goal of Form 72117 is public safety. Florida law requires the Department of Highway Safety and Motor Vehicles to evaluate medical conditions that could impair a person’s ability to drive safely. Loss of consciousness is considered a significant risk factor because it can lead to sudden incapacitation behind the wheel.
By collecting current information from the treating physician, the Medical Advisory Board can make an informed recommendation on whether to:
- Approve continued driving privileges with or without restrictions
- Require additional testing or follow-up reports
- Deny, suspend, or revoke the driving privilege
Florida law requires the department to issue a decision within 90 days after receiving all requested medical information.
Key Questions on HSMV Form 72117
The form is relatively short and focuses on four main areas. Physicians are asked to answer the following:
- Treatment history – How long has the physician treated the patient, and when was the patient last seen in the office?
- Further episodes – Has the patient experienced any additional loss of consciousness since the previous review? If yes, the physician must provide dates and the probable cause of each episode.
- Current treatment – What treatment (if any) is the patient currently receiving? This includes a complete list of medications.
- Safety opinion – From a medical standpoint, does the physician believe it is safe for the patient to continue operating a motor vehicle? Space is provided for comments.
The physician must also sign the form, print their name, include their medical license number, address, telephone number, and the date of completion.
How to Submit Completed Form 72117?
Once the physician completes the form, it must be mailed or faxed to the FLHSMV Medical Review Program:
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 and follow up with the department if they do not receive a decision within the expected timeframe.
Related Forms and the Broader Medical Review Process
Form 72117 is part of a larger medical review framework. Related official forms include:
- HSMV 72423 – Medical Report (the primary initial evaluation form)
- HSMV 72112 – Diabetes/Hypoglycemia Follow-up Form
- HSMV 72118 – Diabetes Form
- HSMV 72190 – Report a Driver Whose Ability is Questionable
The medical review process usually begins when FLHSMV receives a report from a physician, law enforcement, court, family member, or other concerned party. If a review is initiated, the driver is notified in writing and given 45 days to submit the required medical documentation.
For more information on the overall process, visit the official FLHSMV Medical Review Process page.
Important Tips for Drivers and Physicians
- Only a licensed physician familiar with the patient’s medical history should complete Form 72117.
- Provide complete and accurate information. Incomplete forms can delay the review process.
- Drivers may submit additional or updated medical information at any time for reconsideration by the Medical Advisory Board.
- A Certified Driver Evaluation by a Certified Driver Rehabilitation Specialist can also be submitted in support of continued licensure.
- Medical reports submitted under Florida Statute 322.126 are confidential, and no civil or criminal action may be brought against a person who files a good-faith report.
Where to Find Official Resources
Always download forms and verify requirements directly from official Florida government sources:
- Official HSMV Form 72117 PDF
- FLHSMV Forms Page
- FLHSMV Medical Review Program
- Florida Administrative Code Rule 15A-5.005 – Loss of Consciousness
Final Thoughts
Florida HSMV Form 72117 is a vital tool for balancing individual driving privileges with public safety on Florida’s roads. Whether you are a driver undergoing medical review or a physician completing the form, understanding its purpose and requirements helps ensure a smoother process and accurate evaluation.
For the most current version of the form and any updates to medical review procedures, always refer to the official Florida Department of Highway Safety and Motor Vehicles website at www.flhsmv.gov.