Application for Civil Surgeon Designation

Instructions for Application for Civil Surgeon Designation
Department of Homeland Security
U.S. Citizenship and Immigration Services

USCIS
Form I-910
OMB No. 1651-0114
Expires 07/31/2022

What is the Purpose of Form I-910?
Form I-910, Application for Civil Surgeon Designation, is used by physicians seeking designation as a civil surgeon.

What is a Civil Surgeon?

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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.
Unless you are a medical officer of the U.S. Public Health Service (USPHS), you must have civil surgeon designation if
you wish to conduct immigration medical examinations for immigration benefit applicants in the United States. If you are
not a USCIS-designated civil surgeon (or a USPHS medical officer), you are not authorized to conduct immigration
medical examinations for immigration benefit applications in the United States or to complete 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). Only DOSdesignated panel physicians overseas may conduct such examinations. For more information, visit the DOS website at
travel.state.gov/content/travel/en/us-visas/immigrate/the-immigrant-visa-process/interview/interview-prepare/
medical-examination.html.
NOTE: Civil surgeon designation is not required for physicians who perform medical examinations, unrelated to an
immigration benefit, for detainees within the custody of U.S. Immigration and Customs Enforcement (ICE), U.S. Customs
and Border Protection (CBP), and other government entities.

Who Should Use Form I-910?

Use Form I-910 if you are a physician seeking civil surgeon designation to perform immigration medical examinations for
immigration benefit applications in the United States and complete Form I-693.
Do not use Form I-910 if you are a military or public health department physician who qualifies for blanket civil surgeon
designation by USCIS. Public health department physicians may only use the blanket civil surgeon designation to
complete the vaccination assessments for refugees, not asylees, seeking adjustment of status. Military physicians who
qualify for blanket civil surgeon designation may complete all parts of a required immigration medical examination for
members and veterans of the U.S. Armed Forces and certain eligible dependents if the military physician meets certain
conditions. For more information, please visit www.uscis.gov/civilsurgeons.

What Professional Qualifications Are Required for Civil Surgeon Designation?
For USCIS to designate you as a civil surgeon, you must:
1. Have an active and unrestricted license as a doctor of medicine (M.D.) or doctor of osteopathy (D.O.) in the U.S. state
or U.S. territory where you seek to perform immigration medical examinations;
2. Have at least four years of professional experience as a physician in the U.S.; and
3. Have authorization to work in the United States.
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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

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3. Have active medical practices at the locations where you are requesting to perform immigration medical
examinations. USCIS will not grant your civil surgeon designation for locations where you intend to practice only in
the future or where you no longer practice.
NOTE: Civil surgeon designation is at the discretion of USCIS. Although you may meet the specified professional
qualifications and other requirements listed on Form I-910, USCIS cannot guarantee you will receive designation as a
civil surgeon.

What Are the Responsibilities of a Civil Surgeon?

If USCIS designates you as a civil surgeon, you must comply with the following requirements when performing civil
surgeon duties:
1. Truthfully and accurately report the results of an applicant's immigration medical examination and all laboratory
reports on Form I-693, where indicated, and sign the civil surgeon's certification on Form I-693.
Take reasonable steps to ensure the person appearing for the immigration medical examination, including any
laboratory test, vaccinations, or x-rays, is the same person applying for the requested immigration benefit. Generally,
applicants must present a valid government-issued photo identification (for example, a valid unexpired passport or
driver's license) at the time of their immigration medical examination, and you must annotate the type of identification
presented and identification number in Part 5. of Form I-693. 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.
2. Follow Department of Health and Human Services (HHS) regulations and Centers for Disease Control and Prevention
(CDC) guidelines. Civil surgeons must perform the immigration medical examination according to HHS regulations
found at 42 CFR part 34. These regulations include the specific guidelines found in the CDC publication "Technical
Instructions for Civil Surgeons" (Technical Instructions). Civil surgeons should address any questions about the
Technical Instructions directly to CDC. USCIS cannot answer medical questions involving the Technical
Instructions. The Technical Instructions, including periodic updates posted by CDC, are available on the CDC website
at www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/technical-instructions-civil-surgeons.html.
3. Make referrals and file case reports, as required. The CDC's Technical Instructions require you to:
A. Refer the applicant to the local health department if the chest x-ray suggests tuberculosis (TB) or if any other
health-related circumstances are present, as specified in the CDC's Technical Instructions;
B. Ensure testing and therapy are given for diagnoses of communicable diseases of public health significance, as
outlined in the CDC's Technical Instructions; and
C. File a case report with the appropriate public health authorities if required by local laws or regulations. You must
also advise the applicant that you are filing a case report.

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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 U.S. state or U.S. territory or at the locations
associated with your civil surgeon designation; or

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C. Your medical license is restricted and/or you are subject to any disciplinary action; or

D. Your contact information changes (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.

Can USCIS Revoke Civil Surgeon Designation?

USCIS may revoke a civil surgeon's designation at any time. Reasons for revocation include, but are not limited to, your:
1. Failure to continue to meet the professional qualifications required for civil surgeon designation;
2. Failure to meet the responsibilities of a civil surgeon, including failure to follow the CDC's Technical Instructions and
Form I-693 Instructions;
3. Engaging in immigration fraud, including providing false information in any materials provided in the course of
immigration medical examinations; or
4. Engaging in any activity that poses a risk to public health or safety.

General Instructions

USCIS provides forms free of charge through the USCIS website. 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 Contact Center at 1-800-375-5283 and ask that we mail a form to you. The
USCIS Contact Center provides information in English and Spanish. 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. If the request is not signed or if the requisite signature on
the request is not valid, USCIS will reject the request. See 8 CFR 103.2(a)(7)(ii)(A). If USCIS accepts a request for
adjudication and determines that it has a deficient signature, USCIS will deny the request.
Validity of Signatures. USCIS will consider a photocopied, faxed, or scanned copy of the original, handwritten signature
valid for filing purposes. The photocopy, fax, or scan must be of the original document containing the handwritten, ink
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 documents listed in the Specific
Instructions section of these Instructions.

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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 or petition. 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 after we receive them.

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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 also include the
translator's signature, printed name, the signature date, and the translator's contact information.
How To Fill Out Form I-910

1. Type or print legibly in black ink.

2. If you need extra space to complete any item within this application, use the space provided in Part 10. Additional
Information or attach a separate sheet of paper. Type or print your name and Civil Surgeon Identification (CSID)
Number 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.

Specific Instructions

NOTE: You must submit all evidence requested in these Instructions with your application. If you fail to submit
required evidence, USCIS may reject or deny your application for failure to submit requested evidence or supporting
documents in accordance with 8 CFR 103.2(b)(1) and these Instructions.
Part 1. Information About You (The Applicant)
NOTE: Complete Item Numbers 1. - 7. only if you were previously designated as a civil surgeon.
Item Numbers 1. - 3. 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 and the CSID Number issued, if
known.
Item Numbers 4. - 5. 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. Also explain the circumstances
surrounding the revocation in a separate sheet of paper attached to your Form I-910 or in Part 10. Additional
Information. Please note that USCIS may deny your Form I-910 if the grounds upon which your previous designation
was revoked still exist.
Item Numbers 6. - 7. Voluntary Termination. If you voluntarily terminated your previous civil surgeon designation,
select "Yes" and provide the date of voluntary termination. Also explain the circumstances surrounding the voluntary
termination in a separate sheet of paper attached to your Form I-910 or in Part 10. Additional Information.
Item Number 8. Your Full Name. Provide your full legal name as shown on your birth certificate or legal name change
document in the spaces provided.

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Item Number 9. Other Names Used. Provide all other names you have used since birth, including your maiden name,
any nicknames, and any names that appear in your documents. If you need extra space, use Part 10. Additional
Information to provide other names used.
Item Number 10. Date of Birth. Provide your date of birth in mm/dd/yyyy format in the space provided. For example,
type or print October 5, 1967 as 10/05/1967.

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Item Number 11. Gender. Select the box that indicates whether you are male or female.
Item Number 12. USCIS Online Account Number.

Item Number 13. Alien Registration Number (A-Number). Provide your A-Number. Your A-Number is the number
used to identify your immigration records. It begins with an "A" and can be found on correspondence that has been
received from the Department of Homeland Security (DHS) or USCIS. If you do not have an A-Number, type or print
"N/A."
Part 2. Clinical Office Locations

Provide the following information about the locations where you seek to perform immigration medical examinations. If
you intend to perform immigration medical examinations in more than one location, provide the details for each additional
location in Part 10. Additional Information.
You must provide the following information. Failure to provide this information may result in the denial of your
application. USCIS displays information regarding a clinic/practice location and contact information on our website for
people who wish to find a civil surgeon. USCIS will use the contact information listed below for all civil surgeon-related
communications.
Item Number 1. Name of the Clinic/Practice. Provide the name of each clinic or practice where you intend to perform
immigration medical examinations if granted civil surgeon designation.
Item Number 2. Physical Address of the Clinic/Practice. Provide the 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. The address
must be in the United States.
Item Numbers 3. - 9. Clinic/Practice Contact Information. Provide the county of practice, contact information,
telephone number, fax number, email address, and other relevant information for each clinic or practice where you intend
to perform immigration medical examinations if granted civil surgeon designation.
Item Numbers 10. - 11. Mailing Address of the Clinic/Practice. Provide the mailing address of the Clinic/Practice if
different than the physical address of the clinic or practice where you intend to perform immigration medical
examinations if granted civil surgeon designation. The address must be in the United States.
NOTE: You must currently have active practices at the locations where you are requesting to perform immigration
medical examinations. USCIS will not grant civil surgeon designation for locations where you intend to practice in the
future or where you have practiced in the past.
Part 3. Information About Your Status in the United States
Item Numbers 1. - 3. Provide information about your immigration status in the United States that allows you to work
and practice medicine in the United States. A physician meeting the professional qualifications for civil surgeon
designation can receive designation as a civil surgeon only 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 an immigrant in another status that would allow you to practice medicine in the United States. Attach
evidence establishing your lawful status in the United States.
If you select Item Number 1., submit proof that you are a U.S. citizen or national, such as a copy of an unexpired U.S.
passport, birth certificate, or Certificate of Naturalization.
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If you select Item Number 2., submit a copy of your valid Form I-551, Permanent Resident Card. If you are currently
seeking to renew or replace your Form I-551, submit evidence that your Form I-90, Application to Replace Permanent
Resident Card, is pending or approved. For more information, visit
www.uscis.gov/green-card/after-green-card-granted.
If you select Item A. in Item Number 3., you must also provide the information requested in Items B. - H. in Item
Number 3.

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Item B. Date of Last Arrival in the U.S. (mm/dd/yyyy). Provide the date of your last arrival to the United States.
Item C. Form I-94, Arrival-Departure Record. If 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 your Form
I-94). The Form I-94 number is also known as the Arrival/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, CBP may have
issued you an electronic Form I-94 instead of a paper Form I-94. You may visit the CBP website 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
website without charge. If you cannot obtain your Form I-94 from the CBP website, you may obtain it by filing Form
I-102, Application for Replacement/Initial Nonimmigrant Arrival-Departure Record, with USCIS. USCIS does charge a
fee for this service. See the USCIS website at www.uscis.gov/I-102 for more information.
Item D. - G. Passport and Travel Document Numbers. If you used a passport or travel document to travel to the
United States, 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.
Answer Item H. in Item Number 3., if USCIS issued you an Employment Authorization Document (EAD) that
authorizes you to work in the United States. Attach a copy of your valid, unexpired EAD as proof you are authorized to
work in the United States.
Part 4. Medical Degrees

Only doctors of medicine (M.D.) and doctors of osteopathy (D.O.) may receive designation as civil surgeons. Provide the
following:
1. The name(s) of the school(s) you attended;
2. The dates of your attendance and graduation; and
3. The type of medical degree(s) you earned.
If you need extra space to complete this section, use the space provided in Part 10. Additional Information.
Attach a copy of your medical degree(s) to your Form I-910. A copy of the original medical school diploma is required.
If it is a foreign language diploma, a full English translation must be submitted with the foreign document. 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. A Certificate
from Educational Commission for Foreign Medical Graduates is not acceptable for this requirement.
Part 5. Medical Licenses
You must have an active and unrestricted license to practice medicine in each U.S. state or U.S. territory where you seek
to perform immigration medical examinations. For each U.S. state or U.S. territory where you seek to perform
immigration medical examinations, fill out the chart with the following information:
1. The name of the U.S. state or U.S. territory that issued your medical license;
2. The medical license number;
3. The date the medical license was issued;
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4. The date the medical license expires; and
5. Whether the medical license is in good standing.
NOTE: A medical license is in good standing if it is active and unrestricted. If any medical license was ever not in good
standing, you must provide documentation of any previous, current, or pending restriction.
Attach a copy of each of your medical licenses to your Form I-910.

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Part 6. Professional Experience

Item Numbers 1. - 2. To receive designation as a civil surgeon, you must establish you have practiced medicine as a
physician (M.D. or D.O.) for at least four years in the U.S. Provide the following information to cover a period of at least
four years:
1. The names of each employer;

2. The dates of your employment with each employer; and
3. The contact information for each employer.

If you need extra space to complete this section, use the space provided in Part 10. Additional Information.
NOTE: In calculating whether you meet the four-year practice requirement as a physician, do not count your postgraduate 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
letters of employment verification, evaluations, certificates of completion of fellowship program, or medical liability or
malpractice insurance policy. Letters of employment or employee evaluation should be on the company letterhead,
include your dates of employment, position(s) held, job description, and the name, title/position and signature of the
person authorized to verify the employment. A medical liability or malpractice insurance policy, by itself, is insufficient
to establish professional experience, but may be submitted to supplement other evidence listed above. If you are/were
self-employed, submit copies of your business tax returns and your business license(s) or tax receipt(s) covering the tax
return periods.
Part 7. Applicant's Statement, Contact Information, Certification, and Signature

Item Numbers 1. - 6. Select the appropriate box to indicate whether you read this application yourself or whether you
had an interpreter assist you. 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.
A stamped or typewritten name in place of a signature is not acceptable. Your signature will be kept on record to verify
the signature on any submitted Form I-693.
Part 8. Interpreter's Contact Information, Certification, and Signature
Item Numbers 1. - 7. If you used anyone as an interpreter to read the Instructions and questions on this application to
you in a language in which you are fluent, the interpreter must fill out this section; provide his or her name, the name and
address of his or her business or organization (if any), his or her daytime telephone number, his or her mobile telephone
number (if any), and his or her email address (if any). The interpreter must sign and date the application.

Form I-910 Instructions 07/23/20

Part 9. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than
the Applicant
Item Numbers 1. - 9. 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 also need
to submit a completed Form G-28, Notice of Entry of Appearance as Attorney or Accredited Representative, along with
your application.

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NOTE: 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 10. Additional Information

Item Numbers 1. - 7. If you need extra space to provide any additional information within this application, use the space
provided in Part 10. Additional Information. If you need more space than what is provided in Part 10., you may make
copies of Part 10. to complete and file with your application, or attach a separate sheet of paper. Type or print your name
and CSID Number 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 on a separate sheet of paper, but you must annotate in Part
10. that you are attaching a separate sheet. You must submit the separate sheet at the same time you submit your Form
I-910. Type or print your name and CSID Number at the top of each separate sheet; indicate the Page Number, Part
Number, and Item Number of Form I-910 to which the additional information relates; and sign and date each sheet.

We recommend that you print or save a copy of your completed application to review in the future
and for your records

What is the Filing Fee?
The filing fee for Form I-910 is $635.
Exception: Physicians receiving blanket civil surgeon designations are not subject to a fee for receiving the blanket
designation. For more information, please visit www.uscis.gov/civilsurgeons.
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 amounts.
Payments by Check or Money Order
Use the following guidelines when you prepare your check or money order for the Form I-910 filing 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 Paying by Check. If you send USCIS a check, we 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
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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 your check is returned
as unpayable, we may reject your application.

Payments by Credit Card
If you are filing your application at a USCIS Lockbox facility, you can pay your filing fee using a credit card. Please see
Form G-1450, Authorization for Credit Card Transactions, at www.uscis.gov/G-1450 for more information.

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NOTE: By completing this transaction, you agree that you have paid for a government service and that the filing fee,
biometric services fee and all related financial transactions are final and not refundable, regardless of an action USCIS
takes on an application, petition or request, or how long USCIS takes to reach a decision. DO NOT MAIL CASH. You
must submit all fees in the exact amounts.
How To Check If the Fees Are Correct

Form I-910's 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 fee is correct by following one of the steps below.
1. Visit the USCIS website at www.uscis.gov, select "FORMS," and check the appropriate fee; or

2. Visit the USCIS Contact Center at www.uscis.gov/contactcenter to get answers to your questions and connect with a
live USCIS representative. The USCIS Contact Center provides information in English and Spanish. For TTY (deaf
or hard of hearing) call: 1-800-767-1833.

Where To File?

Please see our website at www.uscis.gov/I-910 or visit the USCIS Contact Center at www.uscis.gov/contactcenter to
connect with a USCIS representative for the most current information about where to file this application. The USCIS
Contact Center provides information in English and Spanish. For TTY (deaf or hard of hearing) call: 1-800-767-1833.

Where Is Civil Surgeon Information Listed

We provides a list of civil surgeons for public use. You can access the list in two ways:
1. Visit the USCIS website at my.uscis.gov/findadoctor and enter a zip code or address; or
2. Visit the USCIS Contact Center at www.uscis.gov/contactcenter to get answers to your questions and connect with a
live USCIS representative. The USCIS Contact Center provides information in English and Spanish. For TTY (deaf
or hard of hearing) call: 1-800-767-1833.

When and How Do I Update My Civil Surgeon Informations?
You should notify USCIS within 15 days of any changes relevant to your designation, including address and other
contact information, practice location, and medical license restrictions, suspensions, or revocations.
Visit the USCIS website at www.uscis.gov/I-910 for the most current information about how and where to submit an
update to your civil surgeon information.
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 your new contact information to USCIS with evidence 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.
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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 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 your contact information, or if
USCIS determines you are no longer practicing medicine or performing immigration medical examinations, USCIS may
revoke or terminate your designation and remove you from the public list.
Visit the USCIS Contact Center at https://www.uscis.gov/contactcenter or email [email protected] to
get answers to your questions about civil surgeon designation applications, revocations, and motions to reopen or
questions about completing Form I-910.

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Processing Information

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. USCIS 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 we request an original
document from you, it will be returned to you after USCIS determines it no longer needs your original.
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.

USCIS Forms and Information

To ensure you are using the latest version of this application, visit the USCIS website 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 call the
USCIS Contact Center at 1-800-375-5283 and ask that we mail a form to you. The USCIS Contact Center provides
information in English and Spanish. For TTY (deaf or hard of hearing) call: 1-800-767-1833.
Please visit us at www.uscis.gov/contactcenter to get basic information about immigration services and ask questions
about a pending case. Through our digital self-help tools and live assistance, the USCIS Contact Center provides a
pathway for you to get consistent, accurate information and answers to immigration case questions.

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.

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 are complete, true, and correct. You also authorize the release of any
information from your records that USCIS may need to determine your 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 designation you are seeking at
any time. USCIS' legal authority to verify this information is in 8 U.S.C. sections 1103, 1155, and 1184, and 8 CFR parts
103, 204, 205, and 214. To ensure compliance with applicable laws and authorities, USCIS may verify information
before or after your case is decided.
Form I-910 Instructions 07/23/20

Agency verification methods may include, but are not limited to: review of public records and information; contact
through written correspondence, the internet, fax, 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 designation.
Subject to the restrictions under 8 CFR 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.

DRAFT
Not for
Production
07/29/2020

DHS Privacy Notice

AUTHORITIES: The information requested on this application, and the associated evidence, is collected under the
Immigration and Nationality Act section 232.
PURPOSE: The primary purpose for providing the requested information on this application is to determine whether you
are eligible to be designated as a USCIS Civil Surgeon. DHS uses the information you provide to grant or deny the
immigration benefit you are seeking.
DISCLOSURE: The information you provide is voluntary. However, failure to provide the requested information,
including your Social Security number, and any requested evidence, may delay a final decision or result in a rejection or
denial of your request to be designated as a Civil Surgeon.
ROUTINE USES: DHS may share the information you provide on this application with other Federal, state, local, and
foreign government agencies and authorized organizations. DHS follows approved routine uses described in the
associated published system of records notices [DHS-USCIS-007 - Benefits Information System] and as described in the
Privacy Impact Assessment [DHS/USCIS/PIA-067 Civil Surgeon Designation] which you can find at
www.dhs.gov/privacy. DHS may also share this information, as appropriate, for law enforcement purposes or in the
interest of national security.

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, preparing statements,
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.

Form I-910 Instructions 07/23/20