Table of Changes - Instructions

TABLE OF CHANGES – INSTRUCTIONS

Form I-910, Instructions for Application for Civil Surgeon Designation

OMB Number: 1615-0114

05/10/2016

Reason for Revision: Incorporate standard language and make other updates

Current Section and Page Number	Current Text	Proposed Text
Page 1, What Is the Purpose of This Form?	What Is the Purpose of This Form? Form I-910 is to be used by physicians seeking designation as a civil surgeon.	[Page 1] What Is the Purpose of Form I-910? Form I-910, Application for Civil Surgeon Designation, is to be used by physicians seeking designation as a civil surgeon.
Page 1, What Is A Civil Surgeon?	By law, a civil surgeon is a physician designated by the United States Citizenship and Immigration Services (USCIS) to conduct immigration medical examinations for individuals seeking an immigration benefit in the United States. Civil surgeon designation is required if you wish to conduct immigration medical examinations in the United States. If you are not designated as a civil surgeon by USCIS, you are not authorized to conduct immigration medical examinations in the United States or complete USCIS Form I-693, Report of Medical Examination and Vaccination Record. Civil surgeon designation does not authorize a physician to conduct immigration medical examinations for individuals seeking immigration benefits abroad through the visa issuance process of the United States Department of State (DOS). Those immigration medical examinations are conducted by DOS-designated panel physicians overseas. For more information, please visit the DOS Web site at www.travel.state.gov and search for "Panel Physicians".	[Page 1] What Is A Civil Surgeon? By law, a civil surgeon is a physician designated by U.S. Citizenship and Immigration Services (USCIS) to conduct immigration medical examinations for individuals applying for an immigration benefit in the United States. You must have civil surgeon designation if you wish to conduct immigration medical examinations in the United States, except for medical officers of the U.S. Public Health Service. If you are not designated as a civil surgeon by USCIS, you are not authorized to conduct immigration medical examinations for immigration benefit applications in the United States or to complete USCIS Form I-693, Report of Medical Examination and Vaccination Record. Civil surgeon designation does not authorize you to conduct immigration medical examinations for individuals seeking immigration benefits abroad through the visa issuance process of the U.S. Department of State (DOS). Those immigration medical examinations are conducted by DOS-designated panel physicians overseas. For more information, visit the DOS Web site at www.travel.state.gov and search for "Panel Physicians."
Page 1, Who Should Use Form I-910?	This form should be used by a physician who seeks to perform immigration medical examinations in the United States and completes Form I-693, Report of Medical Examination and Vaccination Record, but who is not currently designated as a civil surgeon. NOTE: Physicians who qualify for blanket civil surgeon designation provided by USCIS are not required to apply for civil surgeon designation on Form I-910. For more information on blank civil surgeon designations, please go to www.uscis.gov/civilsurgeons.	[Page 1] Who Should Use Form I-910? Form I-910 should be used by a physician who is not currently designated, but who is seeking designation to perform immigration medical examinations in the United States and to complete Form I-693. NOTE: Physicians who qualify for blanket civil surgeon designation provided by USCIS are not required to apply for civil surgeon designation on Form I-910. For more information on blank civil surgeon designations, visit www.uscis.gov/civilsurgeons.
Page 1, What Professional Qualifications Are Required For Civil Surgeon Designation?	In order to be designated as a civil surgeon by USCIS, you must: 1. Be licensed without restriction as a Doctor of Medicine (M.D.) or Doctor of Osteopathy (D.O.) in the state in which you seek to perform immigration medical examinations; 2. Have at least 4 years of professional experience as a physician; and 3. Be authorized to work in the United States.	[Page 1] What Professional Qualifications Are Required For Civil Surgeon Designation? [No change] [No change] 2. Have at least four years of professional experience as a physician; and [No change]
Page 1, Are There Other Requirements For Civil Surgeon Designation?	In addition to meeting the professional qualifications, you must: 1. Apply for civil surgeon designation using Form I-910; 2. Submit the completed Form I-910 with the correct filing fee; and 3. Have an active practice at the locations where you are requesting to perform immigration medical examinations. USCIS will not grant your civil surgeon designation for locations where you only intend to practice in the future. Civil surgeon designation is at the discretion of USCIS. Although you may meet the professional qualification and other requirements as listed in Form I-910, there is no guarantee that you will be designated as a civil surgeon.	[Page 1] Are There Other Requirements For Civil Surgeon Designation? [No change] [No change] [No change] [No change] NOTE: Civil surgeon designation is at the discretion of USCIS. Although you may meet the professional qualifications and other requirements listed on Form I-910, there is no guarantee that USICS will designate you as a civil surgeon.
Page 2, What Are the Responsibilities Of A Civil Surgeon?	1. Report the results truthfully and accurately. Civil surgeons are responsible for truthfully and accurately reporting the results of an applicant's immigration medical examination and all laboratory reports on Form I-693 where indicated, and for signing the civil surgeon's certification provided on the form. In this regard, the civil surgeon must take reasonable steps to ensure that the person appearing for the medical examination is the same person applying for the requested immigration benefit. All applicants must present a valid government-issued photo identification (example: valid unexpired passport or driver's license), and the civil surgeon must annotate in Part 1. of Form I-693 the form of identification presented and ID number, if applicable. The law imposes severe penalties for knowingly and willfully falsifying or concealing a material fact or using any false documents in connection with this medical exam. The civil surgeon should also ensure that the applicant's name and Alien Registration Number (A-Number) (if applicable) are at the top of each page of the Form I-693 and that they match the information provided in Part 1. of Form I-693. 2. Follow HHS regulations and CDC guidelines. Civil surgeons are designated with the understanding that they will perform the medical exam according to U.S. Department of Health and Human Services' regulations at 42 CFR part 34. These regulations include the specific guidelines found in Technical Instructions for the Medical Examination of Aliens in the United States (Technical Instructions), published by the Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia. The Technical Instructions (including periodic updates posted by CDC) are available on the CDC Web site at http://www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/technical-instructions-civil- surgeons.html. 3. Make referrals and file case reports, as required. According to CDC's Technical Instructions, civil surgeons are required to: A. Refer the applicant to the local health department if the chest x-ray suggests tuberculosis (TB) or other health- related circumstances are present as described in CDC's Technical Instructions. B. Ensure that any applicant diagnosed with syphilis is treated with the standard treatment regimen described in CDC's Technical Instructions. C. Ensure that testing and therapy are given for diagnoses of chancroid, gonorrhea, granuloma inguinale, or lymphogranuloma venereum. D. Refer the applicant to a Hansen's disease specialist for evaluation to confirm a suspected diagnosis of Hansen's disease (leprosy). E. File a case report with the appropriate public health authorities if a case report is required by local laws or regulations. You must also advise the applicant that a case report is being filed. 4. Notify USCIS of any change(s) relevant to his or her designation as a civil surgeon. Civil surgeons are responsible for notifying USCIS in the event that: A. The civil surgeon ceases to practice medicine; B. The civil surgeon ceases to perform immigration medical examinations in the state in which he or she is designated; or C. There is a change in the civil surgeon's contact information (e.g., name of office, address, telephone number, fax number, or email address). Civil surgeons must notify USCIS within 15 days of the change. See the When and How Do I Update My Civil Surgeon Information section of these instructions for more information.	[Page 2] What Are the Responsibilities Of A Civil Surgeon? If USCIS designates you as a civil surgeon, you must comply with the following requirements listed below: 1. You are responsible for truthfully and accurately reporting the results of an applicant's immigration medical examination and all laboratory reports on Form I-693 where indicated, and for signing the civil surgeon's certification provided on the report. You must take reasonable steps to ensure that the person appearing for the immigration medical examination is the same person applying for the requested immigration benefit. All applicants must present a valid government-issued photo identification (for example, a valid unexpired passport or driver's license), and you must annotate the form of identification presented and ID number in Part 1. of Form I-693, if applicable. The law imposes severe penalties for knowingly and willfully falsifying or concealing a material fact or using any false documents in connection with immigration medical examinations. You should also ensure that the applicant's name and Alien Registration Number (A-Number) (if any) are at the top of each page of Form I-693 and that they match the information provided in Part 1. of Form I-693. 2. Follow Health and Human Services (HHS) regulations and Centers for Disease Control and Prevention (CDC) guidelines. USCIS designates civil surgeons with the understanding that you will perform the medical examination according to HHS’s regulations found at 42 CFR part 34. These regulations include the specific guidelines found in the Technical Instructions for the Medical Examination of Aliens in the United States (Technical Instructions), published by the CDC in Atlanta, Georgia. The Technical Instructions (including periodic updates posted by CDC) are available on the CDC Web site at www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/technical-instructions-civil- surgeons.html. 3. Make referrals and file case reports, as required. According to the CDC's Technical Instructions, you are required to: A. Refer the applicant to the local health department if the chest x-ray suggests tuberculosis (TB) or if other health- related circumstances are present as described in the CDC's Technical Instructions; B. Ensure that testing and therapy are given for diagnoses of communicable diseases of public health significance, as outlined in the CDC’s Technical Instructions; and [Delete] [Delete] C. File a case report with the appropriate public health authorities if a case report is required by local laws or regulations. You must also advise the applicant that a case report is being filed. 4. Notify USCIS of any changes relevant to your designation as a civil surgeon. You are responsible for notifying USCIS in the event that: A. You cease to practice medicine; B. You cease to perform immigration medical examinations in the state or at the locations for which you are designated; or C. There is a change in your contact information (for example, name of office, address, telephone number, fax number, or email address). NOTE: You should notify USCIS within 15 days of the change. See the When and How Do I Update My Civil Surgeon Information section of these Instructions for more information.
Page 3, Can Civil Surgeon Designation Be Revoked?	USCIS may revoke civil surgeon designation for cause, at any time. Reasons for revocation include, but are not limited to, failure to continue to meet the professional qualifications required for civil surgeon designation, failure to meet the responsibilities of a civil surgeon (including failure to follow CDC's Technical Instructions), engaging in immigration fraud, or otherwise engaging in activity that poses a risk to public health or safety.	[Page 3] Can Civil Surgeon Designation Be Revoked? USCIS may revoke a civil surgeon designation. Reasons for revocation include, but are not limited to: failure to continue to meet the professional qualifications required for civil surgeon designation; failure to meet the responsibilities of a civil surgeon (including failure to follow CDC's the Technical Instructions); engaging in immigration fraud; or otherwise engaging in activity that poses a risk to public health or safety.
Page 3, General Instructions	USCIS provides forms free of charge through the USCIS Web site. In order to view, print, or fill out our forms, you should use the latest version of Adobe Reader, which can be downloaded for free at http://get.adobe.com/reader/. Each application must be properly signed and filed. A photocopy of a signed application or a typewritten name in place of a signature is not acceptable. Evidence. You must submit all required initial evidence along with all the supporting documentation with your application at the time of filing. Copies. Unless specifically required that an original document be filed with an application or petition, a legible photocopy may be submitted. Original documents submitted when not required may remain a part of the record, and will not be automatically returned to you. Translations. Any document containing foreign language submitted to USCIS must be accompanied by a full English language translation which the translator has certified as complete and accurate, and by the translator's certification that he or she is competent to translate from the foreign language into English. How To Fill Out Form I-910 1. Type or print legibly in black ink. 3. If you need more space to provide additional information within this application, use the space provided in Part 10., Additional Information. Please provide the Page Number, Part Number, and Item Number to which your additional information relates, to ensure the additional information you submit is considered as part of your application. 2. Answer all questions fully and accurately. If an item is not applicable or the answer is "none," leave the space blank. NOTE: While USCIS does not require you to do so, we suggest that you keep a copy of your application packet for your own records.	[Page 3] General Instructions USCIS provides forms free of charge through the USCIS Web site. In order to view, print, or fill out our forms, you should use the latest version of Adobe Reader, which you can download for free at http://get.adobe.com/reader/. If you do not have Internet access, you may call the USCIS National Customer Service Center at 1-800-375-5283 and ask that we mail a form to you. For TTY (deaf or hard of hearing) call: 1-800-767-1833. Signature. Each application must be properly signed and filed. For all signatures on this application, USCIS will not accept a stamped or typewritten name in place of a signature. Filing Fee. Each application must be accompanied by the appropriate filing fee. (See the What Is the Filing Fee section of these Instructions.) Evidence. At the time of filing, you must submit all evidence and supporting documentation listed in the Specific Instructions section of these Instructions. Copies. You should submit legible photocopies of documents requested, unless the Instructions specifically state that you must submit an original document. USCIS may request an original document at the time of filing or at any time during processing of an application, petition, or request. If USCIS requests an original document from you, it will be returned to you after USCIS determines it no longer needs your original. NOTE: If you submit original documents when not required or requested by USCIS, your original documents may be immediately destroyed upon receipt. Translations. If you submit a document with information in a foreign language, you must also submit a full English translation. The translator must sign a certification that the English language translation is complete and accurate, and that he or she is competent to translate from the foreign language into English. The certification must include the translator’s signature. The Department of Homeland Security (DHS) recommends the certification contain the translator’s printed name and the date and the translator’s contact information. How To Fill Out Form I-910 [no change] 2. If you need extra space to complete any item within this application, use the space provided in Part 9. Additional Information or attach a separate sheet of paper; type or print your name and Civil Surgeon Identification (CSID) Number (if any) at the top of each sheet; indicate the Page Number, Part Number, and Item Number to which your answer refers; and sign and date each sheet. 3. Answer all questions fully and accurately.  If a question does not apply to you (for example, if you have never been married and the question asks “Provide the name of your current spouse”), type or print “N/A,” unless otherwise directed.  If your answer to a question which requires a numeric response is zero or none (for example, “How many children do you have” or “How many times have you departed the United States”), type or print “None,” unless otherwise directed. [Note moved under the Specific Instructions section]
Page 3, Specific Instructions	Part 1. For Previously Designated Civil Surgeons Complete this section only if you were previously designated as a civil surgeon. Item Numbers 1.a. - 1.d. General Information about Previous Civil Surgeon Designation. If you were previously designated as a civil surgeon, select “Yes” and provide the period of prior designation, the USCIS office that granted the designation, and the Civil Surgeon Identification Number (CSID) issued, if known. Item Numbers 2.a. - 2.b. Revocation. If your previous civil surgeon designation was revoked by USCIS, select "Yes" and provide the date of revocation. Attach the revocation letter you received from USCIS, and also include a written explanation of the circumstances surrounding the revocation in a separate letter attached to this application or in Part 10., Additional Information. Please note that USCIS may deny your application for civil surgeon designation if the grounds upon which your previous designation was revoked still exist. Item Numbers 3.a - 3.b. Voluntary Termination. If you voluntarily terminated your previous civil surgeon designation, select "Yes" and provide the date of voluntary termination. You must also include a written explanation of the circumstances surrounding the voluntary termination in a separate letter attached to this application or in Part 10., Additional Information. Part 2. Information About You Item Numbers 1.a. - 1.d. Your Full Name. Provide your last, first, and middle names in the appropriate fields. Item Number 2. Date of Birth. Provide your date of birth in month/day/year (mm/dd/yyyy) format. Part 3. Clinical Office Location(s) A. Required Information Provide the name, physical address, telephone number, fax number, and e-mail address of the clinic or practice where you intend to perform immigration medical examinations if granted civil surgeon designation. Failure to provide this information may result in the denial of your application. If you seek to perform immigration medical examinations in more than one location, provide the details for each additional location in Part 10., Additional Information. NOTE: You must currently have an active practice at the locations where you are requesting to perform immigration medical examinations. USCIS will not grant civil surgeon designation for locations where you only intend to practice in the future. NOTE REGARDING PHYSICAL ADDRESS: The physical address is the address where you are practicing medicine and where applicants will come to have the medical examination performed. The physical address must coincide with the location of your medical clinic or practice. B. Optional Information for Civil Surgeon Locator Additional information may be submitted to USCIS to be included in the public list of civil surgeons. USCIS will update the public list with this information if and when feasible. Part 4. Information About Your Status in the United States In this section, provide information about the status you have been granted in the United States that would allow you to practice medicine in the United States. Attach evidence to verify your legal status in the United States. Item Numbers 1. - 4. Proof of Your Status in the United States. A physician meeting the professional qualifications for civil surgeon designation can only be designated if authorized to work in the United States. Please specify whether you are a U.S. citizen or national, a Legal Permanent Resident, or a nonimmigrant authorized to work as a physician in the United States. (1) If you select Item Number 3., you must also provide the information requested in Item Numbers 3.a. - 3.g.: Item Number 3.a. The date of your last arrival to the United States; Item Number 3.b. Your I-94 Arrival-Departure Record Number, if known; NOTE REGARDING FORM I-94: If U.S. Customs and Border Protection (CBP) or USCIS issued Form I-94, Arrival-Departure Record, to you, provide the I-94 admission number in the fields of this form where it is requested. This number also is known as the Departure Number on some versions of Form I-94. If you do not have an I-94 number, one of the following scenarios may apply: 1. If CBP or USCIS issued Form I-94 to you, but it is now lost or destroyed, you may apply for a replacement by filing Form I-102, Application for Replacement/Initial Nonimmigrant Arrival-Departure Document. 2. If CBP or USCIS did not issue Form I-94 to you and you believe that a Form I-94 should have been issued, you may contact the agency you believe should have issued it to attempt to resolve the matter. 3. If CBP did not issue Form I-94 to you because it captured arrival information electronically, write "N/A" in the fields that request an I-94 Arrival-Departure Record Number. In this instance, it is important for the applicant to provide a passport or travel document number where it is requested on the form. (See below.) Passport and Travel Document Numbers. CBP is exploring automation of Form I-94 Arrival-Departure Record in order to collect arrival-departure information electronically, streamlining arrival and inspection for travelers. If this occurs, CBP may scan a traveler's electronic passport (or, for travelers who do not have a passport, some other similar "travel document") instead of issuing Form I-94. In these instances, applicants must provide passport or travel document numbers - even if they have expired - instead of a Form I-94 number when filing Form I-910. Item Number 3.c. - 3.d. Your passport or travel document number; Item Number 3.e. The name of the country that issued your passport or travel document; Item Number 3.f. The date your passport or travel document expires; and Item Number 3.g. Your current nonimmigrant status. (2) If you select Item Number 4., provide information in the space provided about any other status you have been granted in the United States that would allow you to practice medicine in the United States. Part 5. Medical License(s) Civil surgeons must be licensed to practice medicine in the state(s) or territory(ies) in which they perform immigration medical examinations. For each state or territory in which you seek to perform immigration medical examinations, provide the name of the state or territory that issued your medical license, the medical license number, the date the medical license was issued, and the date it expires. Attach a copy of your medical license(s) to your application. Part 6. Medical Degree(s) Only Doctors of Medicine (M.D.) and Doctors of Osteopathy (D.O.) may be designated as civil surgeons. Provide the names of the school(s) you attended, your dates of attendance, and the type of medical degree(s) earned. Attach a copy of your medical degree(s) to your application. Part 7. Professional Experience To be designated as a civil surgeon, you must have at least 4 years of professional experience as a physician in the United States. Provide your employers' names, the dates of employment, and employers' contact information to cover a period of at least 4 years. NOTE: Time spent in a post-medical school training (including internships or residency programs) cannot be counted toward this experience requirement. Attach evidence to verify your professional experience, such as evaluations, certificates of completion, or letters of employment verification. Part 8. Signature of Applicant After reviewing the certification language, you must sign and date your application; USCIS will return your application as incomplete if you fail to sign and date the form. Part 9. Signature and Contact Information of Person Preparing This Application, If Other Than Applicant If someone other than the applicant prepared this application, that individual must provide the information requested in the space provided. Select Item Number 5. if the preparer may act as a secondary point of contact for you, if USCIS is unable to contact you using the information provided in Part 3., Clinical Office Location(s). After reviewing the declaration, the preparer must sign and date the application. Part 10. Additional Information In the space provided, you may add additional information regarding any item in the form, if needed. Please provide the Page Number, Part Number, and Item Number to which the additional information relates, to ensure the additional information you submit is considered as part of your application. You may also submit a statement with additional information in a separate letter, but you must annotate in Part 10., Additional Information, that you are attaching a separate letter. The letter must be submitted at the same time as this Form I-910 application, and make reference to the Page Number, Part Number, and Item Number of Form I-910 to which the additional information relates. Also include your full name and CSID number, if you have one, on each page of the letter.	[Page 3] Specific Instructions Part 1. Information About You Complete Item Numbers 1.a. – 8. only if you were previously designated as a civil surgeon. Item Numbers 1.a. - 1.d. General Information about Previous Civil Surgeon Designation. If you were previously designated as a civil surgeon, select “Yes” and provide the period of prior designation, the USCIS office that granted the designation, and the CSID Number issued, if known. [Page 4] Item Numbers 2.a. - 2.b. Revocation. If USCIS revoked your previous civil surgeon designation, select "Yes" and provide the date of revocation. Attach the revocation letter you received from USCIS, and also include a typed or written explanation of the circumstances surrounding the revocation in a separate letter attached to this application or in Part 9. Additional Information. Please note that USCIS may deny your application for civil surgeon designation if the grounds upon which your previous designation was revoked still exist. Item Numbers 3.a. - 3.b. Voluntary Termination. If you voluntarily terminated your previous civil surgeon designation, select "Yes" and provide the date of voluntary termination. You must also include a typed or written explanation of the circumstances surrounding the voluntary termination in a separate letter attached to this application or in Part 9. Additional Information. [Delete] Item Numbers 4.a. - 4.c. Your Full Name. Provide your last, first, and middle names in the appropriate fields. Item Numbers 5.a. – 5.c. Other Names Used. Provide all the names you have used, including your maiden name, nicknames, and aliases, if applicable. Item Number 6. Date of Birth. Provide your date of birth in mm/dd/yyyy format. Item Number 7. Gender. Select the box that indicates whether you are male or female. Item Number 8. USCIS Online Account Number (if any). If you have previously filed an application, petition, or request using the USCIS online filing system (previously called USCIS Electronic Immigration System (USCIS ELIS)), provide the USCIS Online Account Number you were issued by the system. You can find your USCIS Online Account Number by logging in to your account and going to the profile page. If you previously filed certain applications, petitions, or requests on a paper form via a USCIS Lockbox facility, you may have received a USCIS Online Account Access Notice issuing you a USCIS Online Account Number. If you received such a notice, your USCIS Online Account Number can be found at the top of the notice. If you were issued a USCIS Online Account Number, enter it in the space provided. The USCIS Online Account Number is not the same as an A-Number. Part 2. Clinical Office Locations A. Required Information Item Numbers 1. – 5. Provide the name, physical address, telephone number, fax number, and email address of the clinic or practice where you intend to perform immigration medical examinations if granted civil surgeon designation. Failure to provide this information may result in the denial of your application. If you seek to perform immigration medical examinations in more than one location, provide the details for each additional location in Part 9. Additional Information. [No change] NOTE REGARDING PHYSICAL ADDRESS: The physical address is the address where you are practicing medicine and where applicants will come to have the medical examination performed. The physical address must match the location of your medical clinic or practice. B. Additional Office Information Item Numbers 6. – 14. You may submit additional information to USCIS to be included in the public list of civil surgeons. USCIS displays this information on our Web site for people who want to find a civil surgeon. USCIS will update the public list with this information when feasible. Part 3. Information About Your Status in the United States In this section, provide information about the immigration status you were granted in the United States that allows you to work and practice medicine in the United States. Attach evidence establishing your legal status in the United States. Item Numbers 1. - 4.g. Proof of Your Status in the United States. A physician meeting the professional qualifications for civil surgeon designation can only be designated as a civil surgeon if authorized to work in the United States. Specify whether you are a U.S. citizen or national, a lawful permanent resident, a nonimmigrant authorized to work as a physician in the United States, or another status that would allow you to practice medicine in the United States. 1. If you select Item Number 1., submit proof that you are a U.S. citizen or national, such as a copy of a U.S. passport, birth certificate, or Certificate of Naturalization. 2. If you select Item Number 2., submit a copy of you valid Form I-551, Permanent Resident Card. If you are currently seeking to renew or replace your Form I-551, submit evidence showing that you are doing so. 3. If you select Item Number 3., you must also provide the information requested in Item Numbers 4.a. - 4.g. Item Number 4.a. Date of Last Arrival in the U.S. (mm/dd/yyyy). The date of your last arrival to the United States. Item Number 4.b. Form I-94 Arrival-Departure Record Number (if any). If U.S. Customs and Border Protection (CBP) or USCIS issued you a Form I-94, Arrival-Departure Record, provide your Form I-94 number and date that your authorized period of stay expires or expired (as shown on Form I-94). The Form I-94 number also is known as the Departure Number on some versions of Form I-94. NOTE: If you were admitted to the United States by CBP at an airport or seaport after April 30, 2013, you may have been issued an electronic Form I-94 by CBP, instead of a paper Form I-94. You may visit the CBP Web site at www.cbp.gov/i94 to obtain a paper version of an electronic Form I-94. CBP does not charge a fee for this service. Some travelers admitted to the United States at a land border, airport, or seaport, after April 30, 2013 with a passport or travel document, who were issued a paper Form I-94 by CBP, may also be able to obtain a replacement Form I-94 from the CBP Web site without charge. If your Form I-94 cannot be obtained from the CBP Web site, it may be obtained by filing Form I-102, Application for Replacement/Initial Nonimmigrant Arrival-Departure Record, with USCIS. USCIS does charge a fee for this service. [Page 5] [see above] [see above] [see above] Item Numbers 4.c. – 4.g. Passport and Travel Document Numbers. If you used a passport or travel document to travel to the United Sates, enter either the passport or travel document information in the appropriate space on the application, even if the passport or travel document is currently expired. [see above] [see above] [see above] [see above] 4. Item Number 5., enter information in the space provided about any other status you were granted under U.S. immigration law in the United States that allows you to work and to practice medicine in the United States. Part 4. Medical Licenses Item Numbers 1.a. – 2.d. You must be licensed to practice medicine in the U.S. state(s) or U.S. territories in which you perform immigration medical examinations. For each U.S. state or U.S. territory in which you seek to perform immigration medical examinations, provide the name of the U.S. state or U.S. territory that issued your medical license, the medical license number, the date the medical license was issued, and the date it expires. Attach a copy of each of your medical licenses to your application. Part 5. Medical Degrees Item Number 1.a. – 2.c. Only Doctors of Medicine (M.D.) and Doctors of Osteopathy (D.O.) may be designated as civil surgeons. Provide the names of the schools you attended, your dates of attendance, and the type of medical degrees earned. Attach a copy of each of your medical degrees to your application. Part 6. Professional Experience Item Numbers 1.a. – 2.h. To be designated as a civil surgeon, you must establish that you have practiced medicine as a physician (M.D. or D.O.) for at least four years. Provide your employers' names, the dates of employment, and your employers' contact information to cover a period of at least four years. NOTE: In calculating whether you meet the requirement of four years’ practice as a physician, DO NOT count your post graduate medical training in an internship or residency program. You can, however, count the time you practiced medicine on the basis of a post-residency fellowship. Submit evidence establishing your professional experience, such as evaluations, certificates of completion, business tax returns and business licenses (for self-employed physicians), or letters of employment verification. Part 7. Applicant’s Statement, Contact Information, Certification, and Signature. Item Numbers 1.a. – 5.b. If someone assisted you in completing the application, select the box indicating that you used a preparer. Further, you must sign and date your application and provide your daytime telephone number, mobile telephone number (if any), and email address (if any). Every application MUST contain the signature of the applicant (or parent or legal guardian, if applicable). A stamped or typewritten name in place of a signature is not acceptable. [Page 6] Part 8. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant Item Numbers 1.a. – 9.b. This section must contain the signature of the person who completed your application, if other than you, the applicant. If the person who completed this application is associated with a business or organization, that person should complete the business or organization name and address information. Anyone who helped you complete this application MUST sign and date the application. A stamped or typewritten name in place of a signature is not acceptable. If the person who helped you prepare your application is an attorney or accredited representative, he or she may be obliged to also submit a completed Form G-28, Notice of Entry of Appearance as Attorney or Accredited Representative, along with your application. Select Item Number 7. if the preparer may act as a secondary point of contact for you, if USCIS is unable to contact you using the information provided in Part 2. Clinical Office Locations. Part 9. Additional Information Item Numbers 1.a. – 7.d. If you need extra space to provide any additional information within this application, use the space provided in Part 9. Additional Information. If you need more space than what is provided in Part 9., you may make copies of Part 9. to complete and file with your application, or attach a separate sheet of paper. Include your name at the top of each sheet; indicate the Page Number, Part Number, and Item Number to which your answer refers; and sign and date each sheet. You may also submit a statement with additional information in a separate letter, but you must annotate in Part 9. Additional Information that you are attaching a separate letter. The letter must be submitted at the same time as this Form I-910 application, and make reference to the Page Number, Part Number, and Item Number of Form I-910 to which the additional information relates. Also include your full name and CSID number, if you have one, on each page of the letter. We recommend that you print or save a copy of your completed application to review in the future and for your records.
Page 6, What Is the Filing Fee?	All applications must be accompanied by a fee of $615. If your application is accepted, USCIS will not refund the fee, regardless of the action taken on the application. Do not mail cash. All fees must be submitted in the exact amounts. Use the following guidelines when you prepare your check or money order for the Form I-910 fee: 1. The check or money order must be drawn on a bank or other financial institution located in the United States and must be payable in U.S. currency; and 2. Make the check or money order payable to U.S. Department of Homeland Security. NOTE: Spell out U.S. Department of Homeland Security; do not use the initials "USDHS" or "DHS." Notice to Those Making Payment by Check. If you send us a check, it will be converted into an electronic funds transfer (EFT). This means we will copy your check and use the account information on it to electronically debit your account for the amount of the check. The debit from your account will usually take 24 hours and will be shown on your regular account statement. You will not receive your original check back. We will destroy your original check, but we will keep a copy of it on file. If the EFT cannot be processed for technical reasons, you authorize us to process the copy in place of your original check. If the EFT cannot be completed because of insufficient funds, we may try to make the transfer up to two times. How to Check If the Fee Is Correct? The filing fee on this form is current as of the edition date appearing in the lower left corner of this page. However, because USCIS fees change periodically, you can verify if the fees are correct by following one of the steps below: 1. Visit the USCIS Web site at www.uscis.gov, select "FORMS," and check the appropriate fee; or 2. Call the USCIS National Customer Service Center at 1-800-375-5283 and ask for the fee information. For TDD (deaf or hard of hearing) call: 1-800-767-1833.	[Page 6] What Is the Filing Fee? The filing fee for Form I-910 is $615. NOTE: The filing fee is not refundable, regardless of any action USCIS takes on this application. DO NOT MAIL CASH. You must submit all fees in the exact amount. Use the following guidelines when you prepare your check or money order for the Form I-910 filing fee: [No change] [No change] [No change] Notice to Those Making Payment by Check. If you send us a check, USCIS will convert it into an electronic funds transfer (EFT). This means we will copy your check and use the account information on it to electronically debit your account for the amount of the check. The debit from your account will usually take 24 hours and your bank will show it on your regular account statement. You will not receive your original check back. We will destroy your original check, but will keep a copy of it. If USCIS cannot process the EFT for technical reasons, you authorize us to process the copy in place of your original check. If USCIS cannot complete the EFT because of insufficient funds, we may try to make the transfer two additional times. [Page 7] How To Check If the Fees Are Correct? Form I-910 filing fee is current as of the edition date in the lower left corner of this page. However, because USCIS fees change periodically, you can verify that the fees are correct by following one of the steps below. [No change] 2. Call the USCIS National Customer Service Center at 1-800-375-5283 and ask for the fee information. For TTY (deaf or hard of hearing) call: 1-800-767-1833.
Page 7, Where To File?	Where To File Please see our Web site at www.uscis.gov/I-910 or call the USCIS National Customer Service Center at 1-800-375-5283 for the most current information about where to file this application. For TDD (deaf or hard of hearing) call: 1-800-767-1833.	[Page 7] Where To File? Please see our Web site at www.uscis.gov/I-910 or call our National Customer Service Center at 1-800-375-5283 for the most current information about where to file this application. For TTY (deaf or hard of hearing) call: 1-800-767-1833.
Page 7, Where Is Civil Surgeon Information Listed?	USCIS provides a list of civil surgeons for public use. The list can be accessed in two ways: 1. Visit the USCIS Web site at www.uscis.gov/civilsurgeons and select “Find a Medical Doctor” from the right side of the page; or 2. Call the USCIS National Customer Service Center at 1-800-375-5283 and follow the instructions in the automated menu. For TDD (deaf or hard of hearing) call: 1-800-767-1833.	[Page 7] Where Is Civil Surgeon Information Listed? USCIS provides a list of civil surgeons for public use. You can access the list in two ways: 1. Visit the USCIS Web site at www.uscis.gov/findadoctor and select “Find a Medical Doctor” from the right side of the page; or 2. Call the USCIS National Customer Service Center at 1-800-375-5283 and follow the instructions in the automated menu. For TTY (deaf or hard of hearing) call: 1-800-767-1833.
Page 7, When and How Do I Update My Civil Surgeon Information?	Civil surgeons must notify USCIS within 15 days of any change(s) relevant to their designation. NOTE: If the change is an update to your contact information that involves practicing in a new state or territory, then you MAY NOT perform immigration medical examinations in the new state or territory until USCIS approves the change. In this case, you must submit the new contact information to USCIS with evidence that you are licensed to practice medicine in the new state or territory in which you seek to perform immigration medical examinations. Visit the USCIS Web site at www.uscis.gov/I-910 for the most current information about where to submit an update to your civil surgeon information. USCIS will also conduct compliance reviews or audits to ensure the accuracy of the civil surgeon's information. As part of these compliance reviews or audits, USCIS may contact civil surgeons on an ad hoc or ongoing annual basis to verify some or all of the information provided on Form I-910. If USCIS is unable to verify a civil surgeon's continued eligibility for designation or confirm contact information or determines that the civil surgeon is no longer practicing medicine or no longer performing immigration medical examinations, USCIS may revoke or terminate the civil surgeon's designation and remove him or her from the public list.	[Page 7] When and How Do I Update My Civil Surgeon Information? You should notify USCIS within 15 days of any changes relevant to your designation. NOTE: If the change is an update to your contact information that involves practicing in a new U.S. state or U.S. territory, then you MAY NOT perform immigration medical examinations in the new U.S. state or U.S. territory until USCIS approves the change. In this case, you must submit the new contact information to USCIS with evidence that you are licensed to practice medicine in the new U.S. state or U.S. territory in which you seek to perform immigration medical examinations. [No change] USCIS will also conduct compliance reviews or audits to ensure the accuracy of civil surgeon information. As part of these compliance reviews or audits, USCIS may contact you on an ad hoc or ongoing annual basis to verify some or all of the information provided on Form I-910. If USCIS is unable to verify your continued eligibility for designation or confirm contact information, or if USCIS determines that you are no longer practicing medicine or no longer performing immigration medical examinations, USCIS may revoke or terminate your designation and remove you from the public list.
Page 8, Frequently Asked Questions	Q. How long is the civil surgeon designation valid? A. Currently, once a physician is designated a civil surgeon, the designation is valid until: (1) USCIS is notified that the physician no longer practices medicine; (2) USCIS is notified that the physician no longer intends to perform immigration medical examinations; (3) The physician's work authorization in the United States expires, if the physician is only authorized to work in the United States for a limited period of time; or (4) Designation is revoked by USCIS. Q. Where is my civil surgeon designation valid? A. Once granted, civil surgeon designation is only valid in the location(s) that you indicated in your application. If you wish to change or add locations associated with your civil surgeon designation, you must notify USCIS within 15 days of such change. See the When and How Do I Update My Civil Surgeon Information section of these instructions for more information. Q. I am a nonimmigrant or an alien authorized to work in the United States on a limited basis. Am I eligible for civil surgeon designation? A. Yes. However, your designation may only be valid to the extent that you have work authorization. For instance, if you are authorized to work in the United States for one year, then your civil surgeon designation, if granted, would only be valid during that year. If your immigration status is extended and you wish to remain designated as a civil surgeon, you must re-apply for designation. Q. Once I am a designated civil surgeon, am I required to perform immigration medical examinations? A. No. You are authorized to perform immigration medical examinations, but not required. However, if you decide to stop performing immigration medical examinations, you must notify USCIS and request removal from the civil surgeon list. Once you are removed from the civil surgeon list, you will be considered to have voluntarily terminated your civil surgeon designation and you must re-apply for civil surgeon designation on Form I-910 in order to be redesignated. Q. Is there a required fee structure for the immigration medical examination? A. No. USCIS does not mandate a fee structure for the immigration medical examination. However, civil surgeons should be open and straightforward with applicants about fees associated with the immigration medical examination.	[Page 7] [Delete entire section]
Page 8, Address Change	If you have changed your address, you must inform USCIS of your new address. For information on filing a change of address go to the USCIS Web site at www.uscis.gov/addresschange or contact the USCIS National Customer Service Center at 1-800-375-5283. For TDD (deaf or hard of hearing) call: 1-800-767-1833. NOTE: Do not submit a change of address request to USCIS Lockbox facilities because USCIS Lockbox facilities do not process change of address requests.	[Page 8] Address Change An applicant who is not a U.S. citizen must notify USCIS of his or her new address within 15 days of moving from your previous address. For information on filing a change of address go to the USCIS Web site at www.uscis.gov/addresschange or contact the USCIS National Customer Service Center at 1-800-375-5283. For TTY (deaf or hard of hearing) call: 1-800-767-1833. NOTE: Do not submit a change of address request to USCIS Lockbox facilities because the Lockbox does not process change of address requests. NOTE: All civil surgeons are responsible for notifying USCIS in writing of any updates to the contact information provided in this Form I-910 within 15 days of the change, regardless whether the civil surgeon is a U.S. citizen or a foreign national. See “When and How Do I Update My Civil Surgeon Information?” for additional information or visit the USCIS Web site at www.uscis.gov/I-910 for information on how to submit a change.
Page 8, Processing Information	Any Form I-910 that is not signed or accompanied by the correct fee, will be rejected with a notice that the Form I-910 is deficient. You may correct the deficiency and resubmit the Form I-910. A Form I-910 is not considered properly filed until accepted by USCIS.	[Page 8] Processing Information USCIS will reject any Form I-910 that is not signed or accompanied by the correct fee, and will send you a notice that Form I-910 is deficient. You may correct the deficiency and resubmit the Form I-910. A Form I-910 is not considered properly filed until accepted by USCIS. Initial Processing. Once USCIS accepts your application we will check it for completeness. If you do not completely fill out this application, you will not establish a basis for your eligibility and USCIS may reject or deny your application. Requests for More Information. We may request that you provide more information or evidence to support your application. We may also request that you provide the originals of any copies you submit. If USCIS requests an original document from you, it will be returned to you after USCIS determines it no longer needs your original. NOTE: If you submit original documents when not required or requested by USCIS, your original documents may be immediately destroyed upon receipt. Decision. The decision on Form I-910 involves a determination of whether you have established eligibility for the designation you are seeking. USCIS will notify you of the decision in writing.
Page 9, USCIS Forms and Information	To ensure you are using the latest version of this form, visit the USCIS Web site at www.uscis.gov where you can obtain the latest USCIS forms and immigration-related information. If you do not have internet access, you may order USCIS forms by calling our toll-free number at 1-800-870-3676. You may also obtain forms and information by calling our USCIS National Customer Service Center at 1-800-375-5283. For TDD (deaf or hard of hearing) call: 1-800-767-1833. As an alternative to waiting in line for assistance at your local USCIS office, you can now schedule an appointment through our Internet-based system, InfoPass. To access the system, visit our Web site at infopass.uscis.gov/. The InfoPass appointment scheduler and follow the screen prompts to set up your appointment. InfoPass generates an electronic appointment notice that appears on the screen.	[Page 9] USCIS Forms and Information To ensure you are using the latest version of this application, visit the USCIS Web site at www.uscis.gov where you can obtain the latest USCIS forms and immigration-related information. If you do not have Internet access, you may order USCIS forms by calling the Forms Request Line at 1-800-870-3676. You may also obtain forms and information by calling the USCIS National Customer Service Center at 1-800-375-5283. For TTY (deaf or hard of hearing) call: 1-800-767-1833. Instead of waiting in line for assistance at your local USCIS office, you can schedule an appointment online at www.uscis.gov. Select “Schedule an appointment online” and follow the screen prompts to set up your appointment. Once you finish scheduling an appointment, the system will generate an appointment notice for you.
Page 9, Penalties	If you knowingly and willfully falsify or conceal a material fact or submit a false document with this Form I-910, USCIS will deny the Form I-910 and may deny any other immigration benefit. In addition, you will face severe penalties provided by law and may be subject to criminal prosecution.	[Page 9] Penalties If you knowingly and willfully falsify or conceal a material fact or submit a false document with your Form I-910, we will deny your Form I-910 and may deny any other immigration benefit. In addition, you will face severe penalties provided by law and may be subject to criminal prosecution.
Page 9, USCIS Compliance Review and Monitoring	By signing this form, you have stated under penalty of perjury (28 U.S.C. Section 1746) that all information and documentation submitted with this form is true and correct. You have also authorized the release of any information from your records that USCIS may need to determine eligibility for the benefit you are seeking and consented to USCIS' verification of such information. The Department of Homeland Security has the authority to verify any information you submit to establish eligibility for the immigration benefit you are seeking at any time. USCIS' legal authority to verify this information is in 8 U.S.C. Sections 1103 and 1222(b) and 8 CFR Part 232.2(b). To ensure compliance with applicable laws and authorities, USCIS may verify information before or after your case has been decided. Agency verification methods may include, but are not limited to: review of public records and information; contact via written correspondence, the Internet, facsimile, or other electronic transmission, or telephone; unannounced physical site inspections of medical clinics or practices; and interviews. Information obtained through verification will be used to assess your compliance with the laws and to determine your eligibility for the benefit sought. Subject to the restrictions under 8 CFR Part 103.2(b) (16), you will be provided an opportunity to address any adverse or derogatory information that may result from a USCIS compliance review, verification, or site visit after a formal decision is made on your case or after the agency has initiated an adverse action which may result in revocation or termination of an approval.	[Page 9] USCIS Compliance Review and Monitoring By signing this application, you have stated under penalty of perjury (28 U.S.C. Section 1746) that all information and documentation submitted with this application is complete, true, and correct. You also authorize the release of any information from your records that USCIS may need to determine eligibility for the designation you are seeking and consent to USCIS verifying such information. DHS has the authority to verify any information you submit to establish eligibility for the immigration benefit you are seeking at any time. USCIS' legal authority to verify this information is in 8 U.S.C. Sections 1103 and 1222(b) and 8 CFR Part 232.2(b). To ensure compliance with applicable laws and authorities, USCIS may verify information before or after your case is decided. Agency verification methods may include, but are not limited to: review of public records and information; contact via written correspondence, the Internet, facsimile, other electronic transmission, or telephone; unannounced physical site inspections of medical clinics or practices; and interviews. USCIS will use information obtained through verification to assess your compliance with the laws and to determine your eligibility for a benefit. [Page 10] Subject to the restrictions under 8 CFR Part 103.2(b)(16), USCIS will provide you with an opportunity to address any adverse or derogatory information that may result from a USCIS compliance review, verification, or site visit after a formal decision is made on your case or after the agency has initiated an adverse action which may result in revocation or termination of an approval.
Page 9, USCIS Privacy Act Statement	AUTHORITIES: The information requested on this form, and the associated evidence, is collected under the Immigration and Nationality Act, section 101, et seq. PURPOSE: The primary purpose for providing the requested information on this form is to determine if you have established eligibility for the benefit for which you are filing. DHS will use the information you provide to grant or deny the benefit sought. DISCLOSURE: The information you provide is voluntary. However, failure to provide the requested information, and any requested evidence, may delay a final decision or result in denial of your form. ROUTINE USES: DHS may share the information you provide with other Federal, State, local, and foreign government agencies and authorized organizations following approved routine uses described in the associated published system of records notices [DHS-USCIS-007 - Benefits Information System and DHS-USCIS-001 - Alien File, Index, and National File Tracking System of Records, which can be found at www.dhs.gov/privacy]. DHS may also make the information available, as appropriate, for law enforcement purposes or in the interest of national security.	[Page 9] USCIS Privacy Act Statement AUTHORITIES: USCIS collects the information requested from a physician seeking to be designated by USCIS as a Civil Surgeon pursuant to Section 232 of the Immigration and Nationality Act, as amended and 8 CFR 232.2. PURPOSE: The primary purpose for requesting the requested information is to determine whether you are eligible to be designated as a USCIS Civil Surgeon. USCIS will use the information you provide to determine your eligibility for designation as a Civil Surgeon. If USCIS does designate you as Civil Surgeon, USCIS will provide your contact information to USCIS applicants who are required to have an immigration-related medical examination completed by a USCIS-designated Civil Surgeon. DISCLOSURE: Providing this information is voluntary. However, failure to provide the requested information, and any requested evidence, may delay a final decision in your case or result in denial of your request to be designated as a Civil Surgeon. ROUTINE USES: USCIS may share the information you provide to USCIS with other federal, state, local, and foreign government agencies and authorized individuals or organizations in accordance with approved routine uses, as described in the associated published system of records notices [DHS-USCIS-001 - Alien File, Index, and National File Tracking System of Records and DHS-USCIS-007 - Benefits Information System] which can be found at www.dhs.gov/privacy. USCIS may also make the information available, as appropriate for law enforcement purposes or in the interest of national security.
Page 10, Paperwork Reduction Act	An agency may not conduct or sponsor an information collection, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The public reporting burden for this collection of information is estimated at 1 hour 51 minutes per response, including the time for reviewing instructions and completing and submitting the form. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Citizenship and Immigration Services, Regulatory Coordination Division, Office of Policy and Strategy, 20 Massachusetts Avenue NW, Washington, DC 20529-2140; OMB No. 1615-0114. Do not mail your completed Form I-910 to this address.	[Page 10] Paperwork Reduction Act An agency may not conduct or sponsor an information collection, and a person is not required to respond to a collection of information, unless it displays a currently valid Office of Management and Budget (OMB) control number. The public reporting burden for this collection of information is estimated at 2 hours per response, including the time for reviewing instructions, gathering the required documentation and information, completing the application, attaching necessary documentation, and submitting the application. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Citizenship and Immigration Services, Regulatory Coordination Division, Office of Policy and Strategy, 20 Massachusetts Ave NW, Washington, DC 20529-2140; OMB No. 1615-0114. Do not mail your completed Form I-910 to this address.
Page 10, Is Your Application Complete?	Please ensure that you have completed the following actions before you file Form I-910 with USCIS: [] Did you fill out the form properly, leaving space(s) blank on any question(s) that did not apply to you? [] Did you provide an original, handwritten signature and date your application? If you had someone else prepare the application on your behalf, did that person sign and date the application? If that person was an attorney, did the attorney submit For G-28 with the application? [] Did you include a check or money order according to the instructions in the section entitled "What is the Filing Fee?" [] Did you attach the required documentation or evidence including proof of your status in the United States, copies of current state medical license(s) and medical degree(s), and proof of your professional experience? [] If you intend to perform immigration medical examinations in more than one location, did you provide details for each additional location in Part 10., Additional Information?	[Page 10] Is Your Application Complete? Ensure that you have completed the following actions before you file Form I-910 with USCIS. [] Did you fill out the application properly, leaving spaces blank on any questions that did not apply to you? [] Did you provide an original, handwritten signature and date your application? [] If you had someone else prepare the application on your behalf, did that person complete Part 8., and sign and date the application? []If that person was an attorney, did the attorney submit For G-28 with the application? [] Did you include a check or money order according to the What Is the Filing Fee section of these Instructions? [] Did you attach the required documentation or evidence including proof of your immigration status in the United States, copies of current state medical licenses and medical degrees, and proof that you meet the professional experience requirement because you have practiced medicine as a physician (M.D. or D.O.) for at least four years? [] If you intend to perform immigration medical examinations in more than one location, did you provide details for each additional location in Part 9. Additional Information?

2