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~ J /"\ Page 1 of l 1 n vr r LVKJUf\ STATE OF FLORIDA DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES MEDICAL REPORTING FORM Section 322.126 (2), (3), Florida Statutes, provides that "Any physician, person, or agency having knowledge of any licensed driver's or applicant's mental or physical disability to drive ... is authorized to report such knowledge to the Department of Highway Safety and Motor Vehicles ... The reports authorized by this section shall be confidential... No civil or criminal action may be brought against any physician, person, or agency who provides the infonnation required herein." When reporting an individual whose driving ability is questionable due to some physical or mental impairment, please complete as much of the information listed below as possible: NAME: DATE OF BIRni: ADDRESS: CITY: 0 Male D Female ZIP CODE: STATE: DRIVER LICENSE NO.: PHYSICAL OR MENTAL HANDICAPS NOTED: rJ D D Seizures Loss of Consciousness 0 D Psychiatric Disturbance n '------' Severe Cardiac Condition Fl Uncontrolled Diabetes D ...___J Drug/Alcohol Addiction I! u Stroke Dementia/Memory Defects Severe Visual Defect D Other: Comments: Date Originating Source (Signature) When this form is completed, please mail directly to: Originating Source (Please Print) (Required) Division of Driver Licenses AT1N: Medical Review Section Neil Kirkman Building~ MS 86 Tallahassee, Florida 32399-0500 FAX (850) 921-6147 Telephone (850) 617-3814 Address (Area Code) http://www.hsmv.state.fl.us//forms/72190.html Telephone 0 ,,., 1 ,,..., { \ f ) L: