Form HSMV 72112. Diabetes/Hypoglycemia Follow-up Form - Florida
The Form HSMV 72112, also known as the Diabetes/Hypoglycemia Follow-up Form, is a document issued by the Florida Department of Highway Safety and Motor Vehicles. This form is used to provide medical follow-up information for individuals with diabetes or hypoglycemia who hold a driver's license in Florida. The form serves as a means for individuals with these medical conditions to provide updated information about their condition and treatment to the Department.
The main purpose of this form is to ensure that drivers with diabetes or hypoglycemia are managing their condition appropriately and are medically fit to operate a motor vehicle safely. It helps the Department assess whether any restrictions or accommodations need to be placed on the driver's license to ensure the individual's safety and the safety of others on the road.
The form typically consists of the following sections:
- Driver's personal information (name, address, date of birth)
- Medical information, including details of the diabetes or hypoglycemia diagnosis
- Information about the treating physician and their contact details
- Details of the treatment plan and medications used
- Declaration of the accuracy of the information provided
- Signature of the driver and treating physician
When filling out this form, it is important to provide accurate and up-to-date medical information. The treating physician should carefully review and confirm the information provided before signing the form. It is also crucial to comply with any specific requirements or guidelines outlined by the physician or the Department regarding the management of the medical condition while driving.
Additional documents that must be attached when submitting this form may include supporting medical documentation, such as laboratory test results or treatment records, to provide a comprehensive overview of the individual's diabetes or hypoglycemia management.
An example of an application for this form would be a driver who has diabetes and previously reported their condition to the Department. The Diabetes/Hypoglycemia Follow-up Form allows the driver to update their medical information, treatment plan, and any changes in their condition to ensure that they continue to meet the necessary medical requirements for driving safely.
A related form is the Medical Reporting Form (Form HSMV 72190), which is used to report various medical conditions or impairments that may affect a person's ability to drive. While the Diabetes/Hypoglycemia Follow-up Form focuses specifically on individuals with diabetes or hypoglycemia, the Medical Reporting Form covers a broader range of medical conditions and requires comprehensive medical information for assessment.