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FLORIDA DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES
APPLICATION FOR SUNSCREENING MEDICAL EXEMPTION
Please submit this form to: Bureau of Motorist Compliance
2900 Apalachee Pkwy, Mail Stop 97
Tallahassee, FL 32399
Application Type:
☐
Original
☐
Duplicate
☐
Lost-in-transit
Section 1: REGISTRANT INFORMATION
Registrant’s Name as It Appears on Driver License
(First, Full Middle/Maiden, & Last Name)
Registrant’s Phone Number
(Voluntary)
Registrant’s Email
(Voluntary)
Sex
Date of Birth
FL DL/ID or FEID/Suffix Number
Registrant’s Mailing Address
City
State
Zip Code
Registrant’s Residential Street Address
City
State
Zip Code
Section 2: APPLICANT WITH MEDICAL CONDITION
Note: Please provide the full printed name of the individual with the medical condition. This individual may be different from the registered owner.
Applicant’s Name as It Appears on Driver License
(First, Full Middle/Maiden, & Last Name)
I certify that I am a person with one of the following medical conditions:
☐ Lupus, ☐ Dermatomyositis, ☐ Albinism, ☐ Total or Facial Vitiligo, ☐ Xeroderma Pigmentosum, ☐ other Autoimmune Disease or other medical condition which
r
equires a limited exposure to light, and I qualify for the medical exemption certificate provided for in Section 316.29545, Florida Statutes.
Under penalties of perjury, I declare that I have read the foregoing document and that the facts stated in it are true.
Signature of Applicant with Medical Condition
Date
Section 3: VEHICLE(S) TO BE EQUIPPED WITH SUNSCREENING MATERIAL
Title Number
Vehicle Identification Number (VIN)
Year
Make
Section 4: PHYSICIAN'S STATEMENT OF CERTIFICATION (See back of form for qualifying authorities.)
Print/Type Name of Certifying Authority
Physician’s Certification or License Number (Required)
Business Street Address
City
State
Zip Code
In my professional opinion, the person named in Section 2, above, is afflicted with one of the following medical conditions:
☐ Lupus (with positive ANA titer), ☐ Dermatomyositis (with positive ANA titer), ☐ Albinism, ☐ Total or Facial Vitiligo, ☐ Xeroderma Pigmentosum,
☐ other Autoimmune Disease or other medical condition which requires a limited exposure to light. If other is selected, diagnosis must be provided below:
__________________ which requires a limited exposure to light, and which qualifies the person, pursuant to section 316.29545, Florida Statutes, to
have sunscreening material on the windshield, side windows, and windows behind the driver, and is exempt from sections 316.2951-316.2957, Florida Statutes.
Under penalties of perjury, I declare that I have read the foregoing document and that the facts stated in it are true.
Signature of Certifying Authority
Telephone Number
Date
Provisions of Law
Section 316.29545, Florida Statutes, provides for the issuance of medical exemption certificates to persons who are
afflicted with Lupus, (SLE or Systemic Lupus Erythematosus), any Autoimmune Disease, or other medical conditions,
which require a limited exposure to light and are permitted to have sunscreening material on the windshield, side
windows, and windows behind the driver which is in violation of the requirements of sections 316.2951-316.2957,
Florida Statutes. The following medical conditions require a limited exposure to light in addition to Lupus:
Dermatomyositis (Autoimmune Disease), Albinism, Total or Facial Vitiligo, and Xeroderma Pigmentosum.
Note: See the reverse side of this form for instructions, fees and additional information.
HSMV 83390 – Rev. 06/23
www.flhsmv.gov
FLORIDA DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES
APPLICATION FOR SUNSCREENING MEDICAL EXEMPTION
Instructions
Instructions vary by application type. Please refer to the application type selected on the top of the application
for the appropriate instructions.
Requirements for an Original application:
1. Form HSMV 83390, Application for Sunscreening Medical Exemption, accurately completed, including
the "Physician's Statement of Certification," which must be completed and signed by one of the
following authorities:
• Physician licensed to practice under Chapters 458, 459, or 460, Florida Statutes.
• Dermatologist licensed to practice under Chapter 458, Florida Statutes.
• Physician who practices medicine in a military medical facility, state hospital or federal prison.
The physician must include the name and address of the facility.
• An advanced registered nurse practitioner licensed under Chapter 464, under the protocol of a
licensed physician.
• Physician assistant licensed under chapter 458 or 459, Florida Statutes.
2. One of the following proofs of identification is required:
• A photocopy of a current Florida Driver License
• A photocopy of a current Florida Identification Card
3. Fees for each applicable vehicle: $ 6.25
Requirements for a Duplicate application:
1. Form HSMV 83390, Application for Sunscreening Medical Exemption, accurately completed.
• The “Physician's Statement of Certification” section does not have to be completed.
• The checkbox for "Duplicate" must be checked on the top of the form.
2. Duplicate fees for each vehicle: $ 6.25
Requirements for a Lost-in-transit application:
1. Form HSMV 83390, Application for Sunscreening Medical Exemption, accurately completed.
• The “Physician's Statement of Certification” section does not have to be completed.
• The checkbox for “Lost-in-transit” must be checked on the top of the form.
2. No fee is charged for issuing a replacement when the certificate has been lost-in-transit and a
completed application is submitted within 180 days of the current issue date.
Additional Information
A medical exemption certificate has no expiration date and is non-transferable. It becomes invalid upon the
sale or transfer of the vehicle identified on the certificate.
HSMV 83390 – Rev. 06/23
www.flhsmv.gov
