Form I-602 (Rev. 12/19/16) Y Page 2
A. Statement by Applicant
Upon admission to the United States I will:
1. Go directly to the physician or health facility named in Part B below; and
2. Present copies of diagnostic tests used in the medical examination to substantiate the diagnosis; and
3. Submit to counseling and such examinations, treatment, and medical regimen as may be required; and
4. Remain under prescribed treatment or observation whether on inpatient or outpatient basis, until I am discharged.
B. Statement by Physician and/or Health Facility
I agree to supply any treatment or observation necessary for the proper management of the applicant's tuberculosis condition.
I agree to submit Form CDC 75.18 to the health officer named below (Section C) either (a) within 30 days of the applicant's
reporting for care, indicating presumptive diagnosis, test results, and plans for future care of the applicant; or (b) 30 days after
receiving Form CDC 75.18, if the applicant has not reported. (NOTE: Military Hospitals should submit this form directly to the
Centers for Disease Control, Atlanta, GA 30333.)
Satisfactory financial arrangements have been made. (NOTE: This statement does not relieve the applicant of submitting such
evidence as the U.S. Consulate may require to establish that the applicant is not likely to become a public charge.)
Local Health Department Outpatient Clinic 1.
This section of Form I-602 may be executed by a private physician, health department, other public or private health facility, or
military hospital. NOTE: Upon arrival of the applicant in the United States, Form CDC 75.18, Report on Alien With Tuberculosis
Waiver, will be sent to the address given below.
To be completed for applicants with active or suspected tuberculosis or who have or have had a physical or mental
disorder and behavior associated with the disorder.
Signature of Physician: Date:
Address: (If military, enter name and address of receiving hospital)
4. Private Practice
Other Public or Private Health Facility3.
I represent: (Check the appropriate box and give the complete name and address of the facility.)
2. Military Hospital
NOTE to Applicant's Sponsor in United States: Arrange for medical care of the applicant and have the physician complete
Section B below.
NOTE to Applicant's Sponsor in United States: If medical care will be provided by a physician who checked Box 3 or 4 in
Section B above, have Section C completed by the local or State health officer who has jurisdiction in the area where the applicant
plans to reside in the United States. Provide the health officer with the address where the applicant plans to reside in the United