Form N-648 Medical Certification for Disability Exceptions

OMB No. 1615-0060; Expires 10/31/10

N-648, Medical Certification
for Disability Exceptions

Department of Homeland Security
U.S. Citizenship and Immigration Services

ATTENTION: ALL parts of this form (except for the "APPLICANT ATTESTATION" below) must be completed by a licensed medical
doctor, licensed doctor of osteopathy, or licensed clinical psychologist. (See instructions)

Part I. BIOGRAPHICAL INFORMATION (Type or print clearly in black ink)

USCIS USE ONLY

Information About The Applicant (Patient). I certify that I have examined:
Applicant Last Name

First Name

Middle Name

This N-648 is:

Alien Registration Number

Address

Sufficient
Insufficient

U. S. Social Security Number

City

State

Zip Code

Date of Birth

Gender

Continued/RFE
Reviewer

E-Mail Address

Telephone Number

Female

Male

Location & Date

Information About The Medical Professional

DRAFT

Last Name

First Name

Middle Name

Business Address

City, State, Zip Code

Telephone Number

License Number

Licensing State

E-Mail Address (if any)

Reminder about Eligibility Requirements
This form is intended for applicants for U.S. citizenship who seek an
exception to the English and civics testing requirements for
naturalization "because of physical or developmental disability or
mental impairment." In general, applicants for naturalization are
required to learn and demonstrate knowledge of the English
language, including an ability to read, write, and speak words in
ordinary usage in the English language, as well as demonstrate
knowledge and understanding of the fundamentals of the history,
principles, and form of government of the United States (civics).

Definition of Disability or Impairment(s):
The disability or impairment(s) rendering the individual incapable of
meeting the testing requirements must be long-term; result from
anatomical, physiological, or psychological abnormalities (which can
be supported by medically acceptable techniques); and result in
functioning so impaired as to render an individual completely unable
to learn and demonstrate the required knowledge.

This definition of disability may be different from definitions used
by the Social Security Administration and Department of Veterans
Affairs or used in worker's compensation claims; however, such
disability determinations may be considered as evidence.

Preparation of the Certification
All questions must be answered fully and accurately, using common
terminology that a person without medical training can understand, with
no abbreviations. Copies of relevant medical reports/records may be
attached to support the claim indicated. However, a supplemental report
is not acceptable as a substitute for any of the responses.
USCIS recommends that the certifying medical professional
complete the fillable electronic Form N-648 provided on the USCIS
website ("Immigration Forms" link www.uscis.gov). If typed or
completed manually, print legibly in black ink.
If you need more space, attach additional pages, indicating item,
applicant's name, and your signature on each. (See instructions for
further details).

Applicant (Patient) Attestation/Release of Information
I,

(Applicant's Name)

, authorize
(Licensed medical doctor, doctor of osteopathy, or clinical psychologist)

to release to U.S. Citizenship and Immigration Services (USCIS) all relevant physical and mental health information related to my medical status for
the purpose of applying for an exception from the English language and U.S. civics requirements for naturalization. I certify under penalty of perjury,
pursuant to Title 28 U.S.C. Section 1746, that the information on this form and any evidence submitted with it are all true and correct. I am aware that
the knowing placement of false information on Form N-648 and related documents may also subject me to civil penalties under 8 U.S.C. 1324c. I
understand that if this form is not completely filled out or if I fail to submit any required documentation, I may not be found eligible for the requested
disability exception.

Has any United States or State government agency made a determination on any disability you are claiming on this form?
Yes

No

NOTE: If you answered "Yes," you may provide information on an attached sheet.

Signature of Applicant (or Applicant's authorized representative)

Date

Form N-648 (Rev. 02/04/09) Y

Applicant's Name

Alien Registration Number

Part II. MEDICAL INFORMATION (Type or print clearly in black ink.)
Background Information
Clinical Psychologist

1. I am a currently licensed: (Check or specify)

Medical Doctor

2. What is the nature of your medical practice?

Family/General Practice

Internal Medicine

Psychiatry/Psychology

Other (specify)

Doctor of Osteopathy

3. How long have you been treating this applicant?
Year(s)

Month(s) or Since

OR
This is my first examination of this applicant.
4. Are you the medical professional regularly treating this applicant for the claimed condition(s)?
Yes (If "Yes," go on to item 5.)
No (If you answered "No," state from whom the applicant usually receives medical
care and explain why you are completing this form.)
Name of Regularly Treating Medical Professional/Clinic and Address

Explanation:

5. Date and location of your most recent examination(s) of the applicant:
Location (if different from business address above; otherwise write "same as above")

Date

6. How often do you examine this patient (applicant)? (Check or specify)
Weekly

Monthly

Annually

Other

Nature and Duration of Disability or Impairment(s)
7. Has the applicant's claimed disability or impairment(s) lasted, or do you expect it to last, 12 months or longer?
Yes

No

8. Is the particular claimed disability or impairment(s) the direct effect of the applicant's illegal use of drugs?
Yes

No
Form N-648 (Rev. 02/04/09) Y Page 2

Applicant's Name

Alien Registration Number

Diagnosis of Disability or Impairments(s)
9. (a) Provide your clinical diagnosis of the applicant's disability or impairment(s) and its origin. Describe the disability
or impairment(s) in terms a person without medical training can understand (See Instructions for examples).
NOTE: The description should include the severity of the effects of the disability or impairment(s).

(b) What medically acceptable clinical or laboratory diagnostic techniques were used to arrive at this diagnosis, as well
as the plan of treatment administered, if any? (List and provide the results and conclusions drawn
from these tests.)

(c) Provide the relevant DSM-IV-TR code(s) for each disability or mental impairment(s) that you described above. If
a DSM-IV-TR code does not exist, write "N/A."

Form N-648 (Rev. 02/04/09) Y Page 3

Applicant's Name

Alien Registration Number

Nexus (connection) Between Disability or Impairment(s) and Inability to Learn/Demonstrate
10. In your professional opinion, based on your examination of the applicant, provide detailed information on the nexus
(connection) between the disability, impairment, or combination of impairments and the applicant's inability to
demonstrate knowledge of English and/or civics (See instructions for examples).
NOTE: This description must address the severity of the effects of the medical condition(s) on:
1. The applicant's ability to learn and demonstrate the required knowledge; and
2. The activities of the applicant's daily life.

Form N-648 (Rev. 02/04/09) Y Page 4

Applicant's Name

Alien Registration Number

Professional Certified Opinion
The law requires that in order to be eligible for the disability exception, the applicant must be unable to fulfill the English and
civics testing required for naturalization. An applicant's difficulty in fulfilling the requirements, such as illiteracy in his or her
native language, is not sufficient by itself to support a finding of eligibility for the exception.
11. ENGLISH REQUIREMENT
In your professional medical opinion, based on your examination of the applicant, the applicant's symptoms, previous
medical records, clinical findings, or tests:
(a) Does the applicant have any disability or impairment(s) that affects his or her ability to function to such a
degree that he or she is unable to learn and demonstrate an ability to speak, read, or write English?
Yes

No

DRAFT

(b) If "Yes," which of the following is the applicant unable to learn and demonstrate? (Check all that apply.)
Speaking

Reading

Writing

12. U.S. HISTORY AND CIVICS REQUIREMENT
In your professional medical opinion, based on your examination of the applicant, the applicant's symptoms, previous
medical records, clinical findings, or tests, does the applicant have any disability or impairment(s) that affects his or her
ability to function to such a degree that he or she is unable to learn and demonstrate knowledge of U.S. history and civics,
even in a language the applicant understands?
Yes

No

NOTE: If you answered "No" to BOTH items 11(a) and (12), the applicant is ineligible for a disability exception.

Sign the "Medical Professional's Certification" below.

MEDICAL PROFESSIONAL' S CERTIFICATION
I certify, under penalty of perjury under the laws of the United States of America, that the information on this form and any evidence
submitted with it are all true and correct. The applicant having consented in Part I to the release of his or her relevant medical
records to U.S. Citizenship and Immigration Services, I will furnish such records, if requested by that agency. I am aware that the
knowing placement of false information on Form N-648 and related documents may also subject me to criminal penalties under Title
18, U.S.C.1546 and civil penalties under Title 8, U.S.C.1324c.
I certify that I have verified the applicant's identity through the following United States or State government-issued
photographic identity document:
Licensed Medical Professional's Signature

Date

Form N-648 (Rev. 02/04/09) Y Page 5