Form HSMV 72118. Diabetes Form - Florida
The Form HSMV 72118, known as the Diabetes Form, is a document issued by the Florida Department of Highway Safety and Motor Vehicles. This form is used by individuals with diabetes to provide medical information related to their condition when applying for or renewing a driver's license in Florida.
The main purpose of this form is to ensure that drivers with diabetes 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)
- Details of the diabetes diagnosis, including the type of diabetes
- Information about the treating physician and their contact details
- Details of the treatment plan, medications, and self-monitoring practices
- 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 related to diabetes. The treating physician should carefully review the information provided before signing the form. Compliance with any specific guidelines or recommendations outlined by the physician or the Department regarding diabetes management while driving is crucial.
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 management.
An example of an application for this form would be a driver who has diabetes and needs to apply for or renew their driver's license. The Diabetes Form allows the driver to provide necessary medical information, treatment details, and demonstrate their ability to manage their condition effectively while driving safely.
A related form is the Diabetes/Hypoglycemia Follow-up Form (Form HSMV 72112), which is used specifically for individuals with diabetes or hypoglycemia to provide updated medical information and treatment details. While the Diabetes Form focuses solely on individuals with diabetes, the Diabetes/Hypoglycemia Follow-up Form covers both diabetes and hypoglycemia. The latter form allows for ongoing monitoring and follow-up of these medical conditions to ensure continued fitness to drive.