Form I-690 (07/30/07)Y Page 2
Supplement for Applicants With Human Immunodeficiency Virus (HIV) Infection or Tubercoulosis (TB)
Upon admission to the United States, I will:
Go directly to the physician or health facility named in
Number 5 of Part C;
Present copies of diagnostic tests used on the visa
examination to substantiate diagnosis;
Submit to counseling and such examinations, treatment and
medical regimen as may be required; and
Part A. Applicant's Sponsor in the United States.
Make arrangements for the applicant's medical care and have
the attending physician or facility complete Part C.
Obtain the necessary endorsements.
Treatment is being provided by a state or local health
department: If a state or local health department will
provide the necessary care and/or treatment to the
applicant, that facility should check block (a) in Number
4 under Part C. The health department is not required to
complete anything else on this form.
Treatment is being provided by a private physician or
by any other private or public facility: If a private
physician, a private medical facility or a public medical
facility (other than a state or local health department) will
provide the applicant's medical care and/or treatment, that
facility should check block (b) or (c) under Number 4 of
Part C, as applicable. In that case, the state or local
health department in the jurisdiction where the applicant
will reside must complete Part D.
Address in the United States where the applicant plans to
reside:
Address (Number and Street)
Part B. Applicant's Statement:
Remain under prescribed treatment or observation whether
on inpatient or outpatient basis, until discharged.
Part C. Statement by Physician or Health Facility:
I agree to supply counseling and any treatment or
observation necessary for the proper management of the
applicant's condition. (Check applicable box(es):
I agree to submit a copy of my evaluation to the Division of
Global Migration and Quarantine (E03), Centers for Disease
Control and Prevention, Atlanta, Georgia 30333, and certify
the following:
I will submit a copy of my evaluation within 30 days
of the date the applicant is required to appear for
evaluation and/or care; and
If at the end of the 30-day period the applicant fails to
appear for evaluation and/or care as required, I will submit
a report to that effect to the CDC.
Satisfactory financial arrangements have been made for the
applicant's medical care and treatment. (This statement does
not relieve the applicant from submitting evidence, as
required by the consular officer or USCIS, to establish that
he or she is not likely to become a public charge (another
ground of inadmissibility under section 212(a)(4) of the
Immigration and Nationality Act).
I represent: (Check the appropriate box and provide the
information requested below.)
Other Public Health Facility
I agree to submit a copy of my evaluation to the health
officer indicated in Part D. (Required if you checked block
(b) or (c) in Number 4 directly above.)
Name of Physician or Facility (Please type or print)
Address (Number and Street)
Part D. Endorsement of Local or State Health Officer :
Endorsement signifies recognition of the physician or facility for
the purpose of providing care for HIV infection or tuberculosis.
If the facility physician who signed in Part C is not in your
health jurisdiction or is not familiar to you, you may wish to
contact the health officer responsible for the jurisdiction, and/or
the physician, before you sign this endorsement.
Official Name of Department (Please type or print.)
Name of Health Department to receive the required notice from the CDC
following the Applicant's arrival in the United States/adjustment of
status. (Please type or print.)
Address (Number and Street)
