Form HSMV77066 "Ignition Interlock Medical Evaluation Form" - Florida

What Is Form HSMV77066?

This is a legal form that was released by the Florida Department of Highway Safety and Motor Vehicles - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2011;
  • The latest edition provided by the Florida Department of Highway Safety and Motor Vehicles;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form HSMV77066 by clicking the link below or browse more documents and templates provided by the Florida Department of Highway Safety and Motor Vehicles.

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Download Form HSMV77066 "Ignition Interlock Medical Evaluation Form" - Florida

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DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES
MEDICAL REVIEW SECTION
Ignition Interlock Medical Evaluation Form
Name:____________________________________ DOB:_____________________ Date:_____________________
Driver License#:________________________________________ Telephone #:_______________________________
Special Note: This form must be completed by a board eligible/board certified pulmonologist. If you do not have a
pulmonary condition, it must be completed by a physician whose specialty relates to your condition.
Dear Doctor:
This patient has indicated that he/she has a medical condition that interferes with the ability to use an ignition interlock
device (IID) as required by law. The IID is a breath alcohol analyzer and is connected to a motor vehicle's ignition. To
start the engine, a driver must blow 1.5 liters of air into the device for 5 seconds in a single breath. The engine will not
start if an unacceptable level of alcohol is detected. The driver must complete the same procedure at periodic intervals
while driving. The standard air volume setting of the IID is 1.5 liters per breath. However, based on the patient’s medical
condition the setting may be reduced to 1 liter per breath. If the patient is unable to blow into the device at the reduced
level, he or she may be eligible for a waiver of this requirement.
1. Current Diagnosis:__________________________________________________________________________
Brief history of illness: ______________________________________________________________________
Current medications: _______________________________________________________________________
Is the patient receiving the best possible treatment for the condition? _________________________________
2. Please provide a copy of a recent pulmonary function test.
3. Based on your medical examination, is the patient capable of breathing into an IID for 5 seconds at the
standard air volume setting of 1.5 liters per breath? Yes __ No __ (if no, #4 must be completed)
4. Should the patient be capable of breathing into the IID for a period of 5 seconds if the setting is reduced to
1 liter per breath? Yes __ No __
Part A or B must be completed:
A. Please explain your recommendation with reference to the pulmonary function test:___________________
________________________________________________________________________________________
________________________________________________________________________________________
B. If you based your recommendation on other (non-pulmonary) medical condition(s)? Please explain in detail:
________________________________________________________________________________________
________________________________________________________________________________________
5. Does the patient have any other medical condition(s) that could affect his or her ability to drive safely?
Yes __ No __ If yes, please explain: ___________________________________________________________
_________________________________________________________________________________________
Signature of Physician: ______________________________________
When Completed, Please Mail to:
Print Physician Name: _______________________________________
Bureau of Motorist Compliance
Medical Review Section, MS 86
Address: _______________________________________
Neil Kirkman Building
Tallahassee, Florida 32399-0570
Telephone Number: _______________________________________
HSMV 77066 (rev 06/11)
DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES
MEDICAL REVIEW SECTION
Ignition Interlock Medical Evaluation Form
Name:____________________________________ DOB:_____________________ Date:_____________________
Driver License#:________________________________________ Telephone #:_______________________________
Special Note: This form must be completed by a board eligible/board certified pulmonologist. If you do not have a
pulmonary condition, it must be completed by a physician whose specialty relates to your condition.
Dear Doctor:
This patient has indicated that he/she has a medical condition that interferes with the ability to use an ignition interlock
device (IID) as required by law. The IID is a breath alcohol analyzer and is connected to a motor vehicle's ignition. To
start the engine, a driver must blow 1.5 liters of air into the device for 5 seconds in a single breath. The engine will not
start if an unacceptable level of alcohol is detected. The driver must complete the same procedure at periodic intervals
while driving. The standard air volume setting of the IID is 1.5 liters per breath. However, based on the patient’s medical
condition the setting may be reduced to 1 liter per breath. If the patient is unable to blow into the device at the reduced
level, he or she may be eligible for a waiver of this requirement.
1. Current Diagnosis:__________________________________________________________________________
Brief history of illness: ______________________________________________________________________
Current medications: _______________________________________________________________________
Is the patient receiving the best possible treatment for the condition? _________________________________
2. Please provide a copy of a recent pulmonary function test.
3. Based on your medical examination, is the patient capable of breathing into an IID for 5 seconds at the
standard air volume setting of 1.5 liters per breath? Yes __ No __ (if no, #4 must be completed)
4. Should the patient be capable of breathing into the IID for a period of 5 seconds if the setting is reduced to
1 liter per breath? Yes __ No __
Part A or B must be completed:
A. Please explain your recommendation with reference to the pulmonary function test:___________________
________________________________________________________________________________________
________________________________________________________________________________________
B. If you based your recommendation on other (non-pulmonary) medical condition(s)? Please explain in detail:
________________________________________________________________________________________
________________________________________________________________________________________
5. Does the patient have any other medical condition(s) that could affect his or her ability to drive safely?
Yes __ No __ If yes, please explain: ___________________________________________________________
_________________________________________________________________________________________
Signature of Physician: ______________________________________
When Completed, Please Mail to:
Print Physician Name: _______________________________________
Bureau of Motorist Compliance
Medical Review Section, MS 86
Address: _______________________________________
Neil Kirkman Building
Tallahassee, Florida 32399-0570
Telephone Number: _______________________________________
HSMV 77066 (rev 06/11)