Fillable N-648-form Form N-648, Medical Certification for Disability Exceptions

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N-648-form Form N-648, Medical Certification for Disability Exceptions

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Form N-648 05/23/19 Page 1
USCIS USE ONLY
Department of Homeland Security
U.S. Citizenship and Immigration Services
OMB No. 1615-0060; Expires 05/31/2021
Form N-648, Medical Certification for
Disability Exceptions
ALL parts of this form, except the "APPLICANT ATTESTATION" and "INTERPRETER'S CERTIFICATION" must be certified by a
licensed medical professional as provided in the instructions for Form N-648. Before certifying this form, the medical professional must
conduct an in-person examination of the applicant. (See instructions for Form N-648 for additional information which is also located in the
"FORMS" section at www.uscis.gov.)
Reminder About Eligibility Requirements
This form is intended for an applicant who seeks an exception to the
English and/or civics requirements due to a physical or
developmental disability or mental impairment that has lasted, or is
expected to last, 12 months or more. An applicant who with
reasonable accommodations provided under the Rehabilitation Act of
1973 can satisfy the English and civics requirements does not need to
submit this form. Reasonable accommodations include, but are not
limited to, sign language interpreters, extended time for testing, and
off-site testing.
Completing and Certifying This Form
All questions or items must be answered fully and accurately.
Responses should utilize common terminology, without
abbreviations, that a person without medical training can understand.
U.S. Citizenship and Immigration Services (USCIS) recommends
that the certifying medical professional use the electronic Form
N-648 located in the "FORMS" section www.uscis.gov. If the
medical professional completes the form by hand, then responses
must be legible and appear in black ink.
Part 1. APPLICANT INFORMATION USPS ZIP Code Lookup
Address (Street Number and Name)
Middle NameFirst Name
USCIS A-Number
City
U.S. Social Security Number
Telephone Number
Zip Code or Postal Code
Gender
State or Province
Date of Birth
Last Name
E-Mail Address (if any)
This N-648 is:
Sufficient
Insufficient
Continued/RFE
Reviewer
Location & Date
I certify that I have examined:
Part 2. MEDICAL PROFESSIONAL INFORMATION
1. Currently licensed as a (Check all that apply): Medical Doctor Doctor of Osteopathy Clinical Psychologist
2. Medical practice type:
Business Address (Street Number and Name) City Telephone Number
License Number Licensing State E-Mail Address (if any)
State or Province
Zip Code or Postal Code
FemaleMale
A-
NOTE: Only medical doctors, doctors of osteopathy, or clinical psychologists licensed to practice in the United States (including the U.S. territories
of 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.
Type or print clearly in black ink. If you need more space to complete an answer, use a separate sheet of paper. Type or print the applicant's name
and Alien Registration Number (A-Number), at the top of each sheet of paper and indicate the part and number of the item to which the answer
refers. You must sign and date each continuation sheet. You must answer and complete each question since USCIS will not accept an incomplete
Form N-648. You may, but are not required to, attach to this completed form supportive medical diagnostic reports or records regarding the applicant.
Type or print clearly in black ink.
Middle NameFirst NameLast Name
Form N-648 05/23/19 Page 2
Applicant's Name USCIS A-Number
3. Date you first examined the applicant regarding the conditions listed in number 1.
Date (mm/dd/yyyy)
Location (if different from business address on Page 1; otherwise type or print "same as business address")
4. Date you last examined the applicant regarding the conditions listed in number 1, if different from above.
Part 3. INFORMATION ABOUT DISABILITY and/or IMPAIRMENT(S)
5. Are you the medical professional regularly treating this applicant for the conditions listed in Item Number 1?
Yes (If "Yes," indicate duration of treatment.)
No (If "No," provide the name of the applicant's regularly treating medical professional on the next page and explain why you are certifying
this form instead of the regularly treating medical professional.)
1. Provide the clinical diagnosis of the applicant's disability and/or impairment, that form the basis for seeking an exception to the English
and/or civics requirements. 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.
2. Provide a basic description of the disability and/or impairments, for example, Intellectual Disability (Severe) is a genetic disorder that
causes lifelong intellectual disability, developmental delays, and other problems.
A-
Date (mm/dd/yyyy)
Location (if different from business address on Page 1; otherwise type or print "same as business address")
Years Months
Form N-648 05/23/19 Page 3
6. Has the applicant's disability and/or impairments lasted, or do you expect it to last, 12 months or more?
7. Is the applicant's disability and/or impairments the result of the applicant's illegal use of drugs?
Name of Regularly Treating Medical Professional and Address
Applicant's Name USCIS A-Number
A-
Business Address (Street Number and Name) City Telephone NumberState or Province
Zip Code or Postal Code
Middle NameFirst NameLast Name
Explanation
Yes (If "Yes,"continue to complete this form.)
No (If "No," the applicant is not eligible for this exception and you need not complete the remainder of the questions. Please go directly to
the "Medical Professional's Certification.")
Yes (If "Yes," the applicant is not eligible for this exception and you need not complete the remainder of the questions. Please go directly to
the "Medical Professional's Certification.")
No (If "No," continue to complete this form.)
8. What caused this applicant's medical disability and/or impairments listed in number 1, if known?
Form N-648 05/23/19 Page 4
10. Clearly describe how the applicant's disability and/or impairments affect his or her ability to demonstrate knowledge and understanding
of English and/or civics.
11. In your professional medical opinion, does the applicant's disability or impairments prevent him or her from demonstrating the
following requirements? (Check all that apply. If none applies, the applicant is not eligible for this exception.)
The ability to:
Applicant's Name USCIS A-Number
A-
9. What clinical methods did you use to diagnose the applicant's medical disability and/or impairments listed in number 1?
Read English
Write English
Speak English
Answer questions regarding United States history and civics, even in a language the applicant understands.
Form N-648 05/23/19 Page 5
Additional Comments (Optional)
12. Was an interpreter used during your examination of the applicant?
Licensed Medical Professional Signature
I certify that this applicant's identity has been verified through the following United States or State government-issued photographic
identity document:
Complete the following if an interpreter was not used during your examination of the applicant between the applicant and medical professional
pertaining to the examinations that form the basis of this Form N-648.
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.
MEDICAL PROFESSIONAL' S CERTIFICATION
I am fluent in English and , the language spoken by this patient. Therefore, an interpreter was not used during
my examinations of this applicant.
All medical professionals must complete the certification below.
Applicant's Name USCIS A-Number
A-
Yes (If "Yes," the interpreter must complete the "Interpreter Certification" section.)
No
Permanent Resident Card
Other Identification (Indicate type and ID Number):
State ID Number:
Date (mm/dd/yyyy)
Form N-648 05/23/19 Page 6
I am fluent as the interpreter, I certify that I am fluent in English and the following language: .
I further certify that I have accurately and completely translated all communications between the medical professional and the applicant that
occurred on , the dates of the examinations that form the basis of this certification.
APPLICANT (PATIENT) ATTESTATION/RELEASE OF INFORMATION
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 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 not be found
eligible for the requested disability exception.
I, , authorize
(Applicant's Name)
(Licensed medical doctor, doctor of osteopathy, or clinical psychologist)
An interpreter must complete, and certify, the section below if an interpreter translated communications between the applicant and medical
professional on the day of the examination that formed the basis of this Form N-648.
INTERPRETER'S CERTIFICATION
Interpreter Information
Interpreter Certification
Applicant's Name USCIS A-Number
A-
Address (Street Number and Name) City State or Province
Zip Code or Postal Code
Middle NameFirst NameLast Name
Was a phone interpreter used?
Yes (If "Yes", the interpreter is not required to complete the information below.)
No (If "No", the interpreter is required to complete the information below.)
Interpreter Signature
Date (mm/dd/yyyy)
Applicant or Applicant's Authorized Representative Signature
Date (mm/dd/yyyy)
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Completed 2 July 2020

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