Form N-648 Medical Certification for Disability Exceptions

Medical Certification for
Disability Exceptions
Department of Homeland Security
U.S. Citizenship and Immigration Services

USCIS
Form N-648
OMB No. 1615-0060
Expires 12/31/2021

► START HERE - Type or print in black ink.
Please read the instructions before examining the applicant and filling out this form.
In general, applicants for naturalization must demonstrate that they understand the English language, including the ability to read,
write, and speak words in ordinary usage. They must also demonstrate knowledge and understanding of the fundamentals of the
history, principles, and form of government of the United States. These are called the “English and civics requirements.” This form is
used for applicants to seek an exception to the English and civics requirements due to a physical or developmental disability or mental
impairment that has lasted, or is expected to last, 12 months or more. Applicants seeking such an exception should submit this form as
an attachment to the Form N-400, Application for Naturalization.
Please note:

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Only medical doctors, doctors of osteopathy, or clinical psychologists can certify the form.

Additionally, they must be licensed to practice in the United States (including the U.S. territories of the Commonwealth of the
Northern Mariana Islands, Guam, Puerto Rico, and the Virgin Islands) to certify the form.
While staff of the medical practice associated with the certifying medical professional certifying the form may assist in its
completion, the certifying medical professional is responsible for the accuracy of the form's content and therefore must sign it.
Answer all the questions regarding medical information, using common terminology that a person without medical training can
understand, with no abbreviations. Failure to fully and accurately complete this form, including all applicable signatures, may
result in the form being found insufficient.

Part 1. Applicant Information

USCIS USE ONLY

1.

This N-648 is:

Applicant's Legal Name

Family Name (Last Name)

Given Name (First Name)

Middle Name (if any)

2.

Alien Registration Number (A-Number) (if any)

3.

Sufficient
Insufficient
Continued/RFE
Reviewer

Date of Birth (mm/dd/yyyy)

► A-

Location & Date

Part 2. Certifying Medical Professional Information
1.

Certifying Medical Professional's Name
Family Name (Last Name)

Given Name (First Name)

Middle Name (if any)

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Part 2. Certifying Medical Professional Information (continued)
2.

► A-

Certifying Medical Professional's Business Address
Street Number and Name

Apt. Ste. Flr.

Number

City or Town

State

ZIP Code

Province

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Postal Code

3.

License Number

5.

Business Telephone Number

7.

I am currently licensed as a (select all that apply):
Medical Doctor

Doctor of Osteopathy

8.

Medical Practice Type:

9.

Did you use an interpreter:

10.

If No, I did not use an interpreter because:

Yes

Country

4.

Licensing State

6.

Email Address (if any)

Clinical Psychologist

No

I am fluent in English and

, the language spoken by this applicant.

This applicant speaks English.

Part 3. Information About Disabilities and/or Impairments
1.

Provide the clinical diagnosis and medical code for all physical or developmental disabilities and/or mental impairments that
affect the applicant's ability to meet the English and/or civics requirements. Also, clearly describe how each disability and/or
impairment prevents the applicant from learning English and/or civics. Responses should use common terminology, without
abbreviations, that a person without medical training can understand. Refer to page 2 of the Instructions for an example. Please
provide the relevant medical code as accepted by the U.S. Department of Health and Human Services (HHS). This includes the
Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases (ICD). For
example, “DSM-V 318.1 Intellectual Disability (Severe)” or “2022 ICD-10-CM F72 Severe intellectual disabilities.”

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Part 3. Information About Disabilities and/or Impairments (continued) ► A2.

What clinical or laboratory diagnostic techniques did you use to diagnose each of the applicant's disabilities and/or
impairment(s) listed in Part 3., Item Number 1.?

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3.

Have any of the applicant's disabilities and/or impairments listed in Part 3., Item Number 1. lasted, or do
you expect any of them to last, 12 months or more? If your answer is “No,” do not complete this form
because the applicant is not eligible for this exception.

Yes

No

4.

Are any of the disabilities and/or impairment(s) listed in Part 3., Item Number 1. the result of the
applicant's illegal use of drugs? If your answer is “Yes” for all of the disabilities or impairments, do not
complete this Form because the applicant is not eligible for this exception.

Yes

No

5.

If yes, for some disabilities or impairments, identify which disabilities or impairments are the result of the applicant's illegal use
of drugs.

6.

For disabilities and/or impairments listed in Part 3., Item Number 1., provide the date you last examined the applicant.
Date (mm/dd/yyyy)

7.

Do any of the disabilities or impairments listed in Part 3., Item Number 1. prevent the applicant from demonstrating the
following? Select all that apply. If none applies, do not complete this Form because the applicant is not eligible for this
exception.
The ability to:

Read English

Speak English

Write English

Answer questions regarding United States history and civics, even in a language the applicant understands.
8.

Is this applicant unable to understand or communicate that they understand the meaning of the Oath of
Allegiance to the United States, because of the disabilities or impairments listed in Part 3., Item Number 1.
even in a language the applicant understands?

Yes

No

Part 4. Ability to Understand Oath of Allegiance
The applicant will not be able to naturalize without a legal guardian, surrogate, or an eligible designated representative unless they are
able to understand and communicate that they understand the meaning of the Oath of Allegiance. The Oath may be administered in
the applicant's language of choice and they may communicate their understanding in any manner (for example, by nodding).
1.

Is the applicant able to understand and communicate that they understand the meaning of the Oath of
Allegiance to the United States?

Form N-648 Edition 07/23/20

Yes

No

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► A-

Part 5. Interpreter Information and Certification

If in-person interpretation services were used during the medical examination, the interpreter must fill out this section, sign, and date
the certification. If telephonic interpretation services were used during the medical examination, the certifying medical professional
must complete all items in this section, except Item Number 6.
1.

Was a telephonic or video facilitated interpreter used during the examination of the applicant?

2.

Interpreter's Name

Yes

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Family Name (Last Name)

Given Name (First Name)

No

Middle Name (if applicable)

Interpreter's Contact Information
3.

Interpreter's Daytime Telephone Number

5.

Interpreter's Email Address (if any)

4.

Interpreter's Mobile Telephone Number (if any)

Interpreter's Certification

I certify that I am fluent in English and the following language,
.
I further certify that I have accurately and completely interpreted all communications between the certifying medical professional and
the applicant that occurred on
, the date(s) of the examination(s) that form the basis of this certification.
6.

Interpreter's Signature (not required for telephonic interpretations)

Date of Signature (mm/dd/yyyy)

Part 6. Applicant's (Patient's) Attestation/Release of Information
1.

I,
authorize

(Applicant's Name),

(the Licensed medical doctor,

doctor of osteopathy, or clinical psychologist completing this form) to release to U.S. Citizenship and Immigration Services
(USCIS) all relevant physical and mental health information related to my medical status for the purpose of applying for an
exception from the English language and U.S. civics requirements for naturalization. I certify under penalty of perjury, pursuant
to 28 U.S.C. section 1746, that the information I provided to the certifying medical professional is true and correct. I certify
under penalty of perjury, pursuant to 28 U.S.C. section 1746, that I have attended an appointment with
(Licensed medical doctor, doctor of osteopathy, or clinical psychologist) and was then
diagnosed by him or her. I am aware that the knowing placement of false information on Form N-648 and related documents
may also subject me to civil penalties under 8 U.S.C. section 1324c and INA section 274C. I understand that if this form is not
completely filled out or if I fail to submit any required documentation, I may be found ineligible for the requested medical
disability exception.
2.

Applicant Signature (or mark if applicant is unable to sign)

Form N-648 Edition 07/23/20

Date of Signature (mm/dd/yyyy)

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Part 7. Medical Professional's Certification

► A-

I certify that:
1.

I have examined the applicant/patient listed in Part 1. above.

2.

I will furnish relevant medical records to USCIS, if requested to do so by USCIS, based on the applicant's consent in
Part 6.

3.

This applicant's identity has been verified through the following United States or State government-issued photographic
identity document:

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Permanent Resident Card

State ID Number:

Other Identification (Indicate type and ID Number):

Additionally, I certify, under penalty of perjury under the laws of the United States of America, that the information on this form and
any evidence submitted with it are all true and correct. I am aware that the knowing placement of false information on Form N-648
and related documents may also subject me to criminal penalties including under 18 U.S.C. section 1546, civil penalties under 8
U.S.C. section 1324c and Immigration and Nationality Act (INA) section 274C, and civil license suspension or revocation by the
appropriate authorities.
4.

Certifying Medical Professional Signature

Form N-648 Edition 07/23/20

Date of Signature (mm/dd/yyyy)

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