Fillable Form N-648: Medical Certification for Disability Exceptions (USCIS)

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Form N-648: Medical Certification for Disability Exceptions (USCIS)

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The Form N-648: Medical Certification for Disability Exceptions (USCIS) form is 9 pages long and contains:

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  • 104 other fields

Country of origin: US
File type: PDF

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U.S. Citizenship and Immigration Services (USCIS) is an office of the U.S. Branch of Homeland Security (DHS) that oversees the nation's naturalization and migration framework. It is a successor to the Immigration and Naturalization Service (INS), which was disintegrated by the Homeland Security Act of 2002 and supplanted by three segments inside the DHS: USCIS, Immigration and Customs Enforcement (ICE), and Customs and Border Protection (CBP).

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Form N-648 Edition 07/23/20
Page 1 of 9
Applicant's Current Physical Address
Medical Certification for
Disability Exceptions
Department of Homeland Security
U.S. Citizenship and Immigration Services
USCIS
Form N-648
OMB No. 1615-0069
Expires 12/31/2021
START HERE - Type or print in black ink.►
Part 1. Applicant Information
1.
Applicant's Other Information
3.
Please read the instructions before examining the applicant and filling out this form.
If you are using an interpreter during the examination (either in person or by phone), you must ask the interpreter the following
questions and affirm their response:
Only medical doctors, doctors of osteopathy, or clinical psychologists licensed to practice in the United States (including the U.S.
territories of the Commonwealth of the Northern Mariana Islands (CNMI), Guam, Puerto Rico, and the Virgin Islands) are authorized
to certify the form. While staff of the medical practice associated with the medical professional certifying the form may assist in its
completion, the medical professional is responsible for the accuracy of the form's content. Failure to fully and accurately complete
this form, including all applicable signatures, may result in the form being found insufficient.
Do you certify that you are fluent in English and the following language,
Do you further certify that you will accurately and completely interpret all communications between the applicant
,
and me (the medical professional)?
I certify that I have examined the following applicant.
Applicant's Legal Name
2.
Family Name (Last Name)
Given Name (First Name)
Middle Name (if any)
Street Number and Name
City or Town
Apt. Ste. Flr. Number
ZIP CodeState
Province Postal Code Country
Alien Registration Number (A-Number) (if any)
5.
►
A-
4. U.S. Social Security Number (if any)
►
Date of Birth (mm/dd/yyyy)
Gender
Male Female
6.
Applicant's Email Address (if any)
Applicant's Telephone Number7. 8.
USCIS USE ONLY
This N-648 is:
Sufficient
Insufficient
Continued/RFE
Reviewer
Location & Date
USPS ZIP Code Lookup
Form N-648 Edition 07/23/20
Page 2 of 9
Part 2. Medical Professional Information
7. I am currently licensed as a (select all that apply):
Medical Doctor Doctor of Osteopathy Clinical Psychologist
Provide the clinical diagnosis of all physical or developmental disabilities and/or mental impairments that may affect the
applicant's ability to demonstrate an understanding of the English language and/or a knowledge and understanding of the
fundamentals of the history and the principles and form of government of the United States. If applicable, please provide the
relevant medical code as accepted by the 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 “2015/16 ICD-10-CM F72 Severe intellectual disabilities.”
1. Medical Professional's Name
Family Name (Last Name) Given Name (First Name)
Middle Name (if any)
2. Medical Professional's Business Address
Street Number and Name
City or Town
Apt. Ste. Flr. Number
ZIP CodeState
Province Postal Code Country
3. License Number 4. Licensing State
Email Address (if any)Business Telephone Number5. 6.
8. Medical Practice Type:
Part 3. Information About Disabilities and/or Impairments
1.
Form N-648 Edition 07/23/20
Page 3 of 9
Part 3. Information About Disabilities and/or Impairments (continued)
Provide a basic description of all the disabilities and/or impairments listed in Part 3, Item 1. For example, “Intellectual
Disability (Severe) is a genetic disorder that causes lifelong intellectual disability, developmental delays, and other problems.”
2.
When did each disability or impairment listed in Part 3., Item Number 1., begin?3.
Date (mm/dd/yyyy) If you need extra space to complete this section, use the space provided
below.
4. Date(s) of Diagnosis (mm/dd/yyyy)
If you need extra space to complete this section, use the space provided below.
What caused each of this applicant's medical disabilities and/or impairments listed in Part 3., Item Number 1., if known?5.
Form N-648 Edition 07/23/20
Page 4 of 9
Part 3. Information About Disabilities and/or Impairments (continued)
Describe how each relevant disability and/or impairment affects specific functions of the applicant's daily life, including the
ability to work or go to school, that may be related to the ability to learn civics and/or English, including the ability to read,
write and speak words in ordinary usage of the English language. Explain the basis of your assessment, including known
symptoms of condition, tests conducted, observations, etc.
8.
Describe the severity of each disability and/or impairment listed in Part 3., Item Number 1. Explain the basis of your
assessment, i.e. known symptoms of condition, tests conducted, observations, etc.
7.
Have any of the applicant's disabilities and/or impairments lasted, or do you expect any of them to last, 12 months or more?9.
Yes No
What clinical methods did you use to diagnose each of the applicant's medical disabilities and/or impairment(s) listed in Part 3.,
Item Number 1.?
6.
Form N-648 Edition 07/23/20
Page 5 of 9
Part 3. Information About Disabilities and/or Impairments (continued)
Are any of the disabilities and/or impairment(s) the result of the applicant's illegal use of drugs?11.
Yes No
If yes, provide an explanation as to which disabilities or impairments are the result of the applicant's illegal use of drugs.12.
NOTE: If you answered “Yes” and all of the applicant's disabilities and/or impairments are the result of the applicant's illegal use of
drugs, the applicant is not eligible for this exception and you need to go directly to Part 6. Medical Professional's Certification.
Clearly describe how each of the applicant's disabilities and/or impairments affects his or her ability to demonstrate knowledge
and understanding of English and/or civics.
13.
Provide an explanation as to which disabilities or impairments are expected to last over 12 months and why.10.
NOTE: If you answered “No,” the applicant is not eligible for this exception and you need to go directly to Part 6. Medical
Professional's Certification.
In your professional medical opinion, do any of the applicant's disabilities or impairments prevent him or her from demonstrating
the following requirements? (Select all that apply. If none applies, the applicant is not eligible for this exception.)
14.
The ability to:
Read English
Write EnglishSpeak English
Answer questions regarding United States history and civics, even in a language the applicant understands.
Date and location you first examined the applicant regarding the condition(s) listed in Part 3., Item Number 1.15.
A.
Date (mm/dd/yyyy)
Form N-648 Edition 07/23/20
Page 6 of 9
Part 3. Information About Disabilities and/or Impairments (continued)
Date and location you last examined the applicant regarding the conditions listed in Part 3., Item Number 1., if different from
above.
16.
A.
Date (mm/dd/yyyy)
B. Location (if different from business address provided in Part 2., otherwise select “same as business address”).
Street Number and Name
City or Town
Apt. Ste. Flr. Number
ZIP CodeState
Province Postal Code Country
B. Location (if different from business address provided in Part 2., otherwise select “same as business address”).
Street Number and Name
City or Town
Apt. Ste. Flr. Number
ZIP CodeState
Province Postal Code Country
Are you the medical professional who regularly treats this applicant for the conditions listed in Part 3., Item Number 1.?17.
Yes No
If you answered “Yes,” indicate the duration of treatment and skip Item Number 20. - 22.18.
Years Months
Please indicate the frequency of treatment.19.
Weekly Monthly Yearly Other
Name of Regularly Treating Medical Professional20.
Family Name (Last Name)
Given Name (First Name) Middle Name (if applicable)
Business Address and Phone Number of Regularly Treating Medical Professional21.
Street Number and Name
City or Town
Apt. Ste. Flr. Number
ZIP CodeState
Province Postal Code Country
Same as business address
Same as business address
Form N-648 Edition 07/23/20
Page 7 of 9
Explanation for why you are certifying this form instead of the regularly treating medical professional.22.
Did you use an interpreter when you examined the applicant?23.
Yes No
NOTE: If you answered “Yes,” the interpreter must complete Part 4. Interpreter's Certification. If you used a telephonic
interpreter, please complete all Items in Part 4. except Item Numbers 6. and 7.
Additional Comments (Optional)
Part 3. Information About Disabilities and/or Impairments (continued)
Part 4. Interpreter's Certification
The interpreter must complete and certify the section below if an interpreter interpreted communications between the applicant and
medical professional on the day of the examination that formed the basis of this Form N-648.
1.
Family Name (Last Name) Given Name (First Name)
Middle Name (if applicable)
Interpreter's Name
2. Interpreter's Mailing Address
City or Town
Street Number and Name Apt. Ste. Flr. Number
Postal Code Country
State ZIP Code
Province
Interpreter's Contact Information
Interpreter's Daytime Telephone Number3.
Interpreter's Email Address (if any)5.
Interpreter's Mobile Telephone Number (if any)4.
Form N-648 Edition 07/23/20
Page 8 of 9
Part 4. Interpreter's Certification (continued)
Interpreter's Signature 7. Date of Signature (mm/dd/yyyy)
Interpreter's Certification
I further certify that I have accurately and completely interpreted all communications between the medical professional and the
I certify that I am fluent in English and the following language,
applicant that occurred on
6. .
, the dates of the examinations that form the basis of this certification.
Certification for Telephonic Interpreter (to be completed by the medical professional)
Was a telephonic interpreter used during the examination of the applicant?8.
Yes (go to question 9.) No
If you answered yes, did you ask the interpreter to affirm that he or she speaks fluent English and the applicant's language and
that he or she will accurately and completely interpret all communications between you and the applicant?
9.
Yes No
If yes, did the interpreter answer in the affirmative?10.
Yes No
Part 5. Applicant's (Patient's) Attestation/Release of Information
I,1. (Applicant's Name),
authorize (Licensed medical doctor,
doctor of osteopathy, or clinical psychologist) to release to U.S. Citizenship and Immigration Services 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 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
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 disability exception.
(Licensed
Applicant or Applicant's Authorized Representative's Signature2. Date of Signature (mm/dd/yyyy)
Part 6. Medical Professional's Certification
Complete the following if you did not use an interpreter to communicate with the applicant during the examinations that form the
basis of this Form N-648.
I did not use an interpreter during my examinations of this applicant because:1.
I am fluent in English and
applicant.
, the language spoken by this
This applicant speaks English.
Form N-648 Edition 07/23/20
Page 9 of 9
Part 6. Medical Professional's Certification (continued)
All medical professionals must complete the certification below.
I certify that this applicant's identity has been verified through the following United States or State government-issued
photographic identity document:
2.
Permanent Resident Card
Other Identification (Indicate type and ID Number):
State ID Number:
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 will furnish relevant medical records to USCIS, if requested to do so by USCIS, based on
the applicant's consent. 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.
Licensed Medical Professional Signature
3.
Date of Signature (mm/dd/yyyy)
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Form N-648: Medical Certification for Disability Exceptions (USCIS)

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Completed 15 October 2020

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