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Chapter 4: Review of Medical Examination Documentation


A. Results of the Medical Examination


The physician must annotate the results of the examination on the following forms: 


Panel Physicians


Panel physicians must annotate the results of the medical examination on the Medical Examination for Immigrant or Refugee Applicant (1991 TB Technical Instructions) (Form DS-2053) or the Medical Examination for Immigrant or Refugee Applicant (2007 TB Technical Instructions) (Form DS-2054), and related worksheets.[1] As of October 1, 2013, panel physicians only use DS-2054. The DS-2053 is no longer used after that date. 


Civil Surgeons


Civil surgeons must annotate the medical examination results on the Report of Medical Examination and Vaccination Record (Form I-693). 


B. Documentation Completed by Panel Physician 


Since a State Department Consular Officer reviews the medical documentation completed by a panel physician as part of the overseas visa process, a USCIS Officer may assume that the medical documentation is properly completed.[2] The Technical Instructions for Panel Physicians may differ from the Technical Instructions for Civil Surgeons. As long as the DS form is properly completed, the officer should accept the finding of the consular officer as correct.


If the USCIS Officer notices a significant irregularity such as an omission of a particular section, the officer may issue a Request for Evidence (RFE) to have a civil surgeon in the United States complete the missing part(s) of the medical examination. A civil surgeon should address any deficiency by completing the respective parts of a Form I-693 according to the Technical Instructions for Civil Surgeons issued by CDC.[3] In this case, because the DS form was completed by a panel physician, the officer should retain the original document. The RFE must specify which sections of Form I-693 have to be completed by a civil surgeon. This should only happen in rare instances. 


Applicants who have already been examined abroad and are not required to repeat the medical examination in the United States may still have to show proof of the vaccination requirement.[4] See Chapter 3, Applicability of Medical Examination and Vaccination Requirement [8 USCIS-PM B.3] for specific information on who is required to be examined and to what extent. 


C. Documentation Completed by Civil Surgeon

 

1. Civil Surgeon Designation


Except for physicians who are Public Health Service Officers, only physicians designated by USCIS to act as civil surgeons may conduct an immigration medical examination in the United States and complete Form I-693.[5] Form I-693 can only be used for immigration benefits that are granted in the United States. Only doctors of medicine (M.D.) and doctors of osteopathy (D.O.) who are currently licensed to practice as physicians may be designated.[6] See INA 232 and 8 CFR 232. The physician must be designated as a civil surgeon at the time of the completion of the medical examination.


To determine whether the physician is designated as a civil surgeon, the officer should consult the designated civil surgeon list through the civil surgeon locator on uscis.gov.


If the officer has questions as to the past designation of a civil surgeon, the officer should contact the appropriate civil surgeon POC(s). 


2. Complete Form


The following requirements must always be met regarding any Form I-693 submitted to USCIS:


  • The form must be completed legibly;

 






  • The form must be in a sealed envelope as detailed in the form’s instructions. 


If the above requirements are not met, or if there is evidence that the envelope has been tampered with, the officer must return the original Form I-693 to the applicant for corrective action. Whenever an original is returned to the applicant, the officer should retain a copy. 


A response to an RFE is acceptable if it is completed by a civil surgeon in one of the following ways:


  • The civil surgeon annotates the original medical examination in the deficient part(s), and both the applicant and the civil surgeon re-sign and re-date their respective certifications.

 

  • The civil surgeon re-completes an entirely new Form I-693, and corrects for the original deficiency.



The applicant may return to the original civil surgeon who performed the immigration medical exam or a new civil surgeon to correct the form.


The civil surgeon must place the corrected form[13] Along with the original Form I-693, if separate from the corrected form.  in a sealed envelope. The applicant must then return the sealed envelope to USCIS.


3. Signatures


The applicant, the civil surgeon, and any other health care provider who evaluated the applicant as part of the immigration medical examination should sign the form, to verify that the content of their representations is truthful.


Signature of the Civil Surgeon 


The civil surgeon’s signature must be an original signature. There is no exception to this requirement. Stamps of the physician’s signature or other substitutes, or copies of the civil surgeon’s original signature, are not acceptable.


As outlined in CDC’s Technical Instructions, the civil surgeon is only permitted to sign the Form I-693 after he or she has completed the entire medical examination. An examination is not completed until any prescribed treatment for a Class A condition has been administered. 


There may be circumstances when an applicant refuses to undergo one part of the examination, but the civil surgeon certifies the form with a notation that part of the exam is not complete. In these cases, the officer should issue an RFE to the applicant for corrective action.


The civil surgeon might also diagnose a Class A condition for which the applicant refuses treatment. The civil surgeon might then annotate the Class A condition but still certify and sign the form. In this case, the officer should not return the form for corrective action. The officer should determine that the applicant is inadmissible and ask the applicant to request a waiver, if available.[14] See Volume 9, Waivers, Part C, Waivers for Health-Related Grounds of Inadmissibility [9 USCIS-PM C] for more on waivers. 


Signature of the Health Department 


In agreement with CDC, USCIS granted blanket civil surgeon designation to local and state health departments in the United States. This blanket designation allows health departments to complete the vaccination portion of Form I-693 for refugees seeking adjustment if they have a physician who meets the professional qualifications for a civil surgeon. If a refugee only requires the vaccination assessment, the only parts of the form that need to be completed are the applicant’s information, the vaccination assessment, and the certifications. The other parts are irrelevant and do not have to be submitted. 


If the health department physician is completing only a vaccination assessment for refugees seeking adjustment, the physician’s signature may be either an original (handwritten) or a stamped signature, as long as it is the signature of the health department physician. The attending nurse may, but does not have to, co-sign with the physician. The signature of the physician must be accompanied by the health department’s stamp or raised seal, whichever is customarily used. 


If the health department does not properly sign, the officer should return the medical documentation to the applicant for corrective action.[15] See Part C, Civil Surgeon Designation and Revocation [8 USCIS-PM C] for more information on the blanket civil surgeon designation for health departments. 


Signature of a Military Physician designated as a Civil Surgeon for Members and Veterans of the Armed Forces


To ease the difficulties encountered by physicians and applicants in the military, USCIS issued a blanket civil surgeon designation to qualifying military physicians to permit them to perform the immigration medical examination and complete the Form I-693 for eligible members and veterans of the U.S. armed forces and their dependents.[16] See Part C, Civil Surgeon Designation and Revocation [8 USCIS-PM C] for more information on the blanket civil surgeon designation for military physicians. 


Pursuant to the understanding reached between USCIS and the CDC, military physicians who qualify under this blanket civil surgeon designation may perform the entire immigration medical examination as long as the exam is conducted in the United States on the premises of a Military Treatment Facility (MTF) and conducted for a U.S. armed forces member, veteran, or dependent who is eligible to receive medical care at the MTF.


If operating under the blanket civil surgeon designation for military physicians, a physician’s signature may be either an original (handwritten) or stamped signature, as long as it is the signature of a qualifying military physician. Nurses and other health care professionals may, but are not required to, co-sign the form. The signature of the physician must be accompanied by the official stamp or raised seal of the MTF, whichever is customarily used.


If the military physician does not properly sign, the officer should return the medical documentation to the applicant for corrective action.


Signature of the Applicant


The applicant or the civil surgeon may complete the section about the applicant’s information. The civil surgeon must always verify the applicant’s identity by requiring a government-issued ID, as stated in CDC’s Technical Instructions. 


The applicant must sign the certification only when instructed by the civil surgeon. By signing the form, the applicant attests that he or she consented to the medical examination and that any information provided in relation to the medical examination is truthful. 


Whenever the civil surgeon orders a test that he or she does not perform personally, the civil surgeon must ensure that the physician or staff to whom the applicant is referred checks the identity of the applicant by requesting a government-issued ID.[17] By signing the form, the civil surgeon certifies that he or she has examined the applicant according to the procedures and requirements outlined in the Technical Instructions, Form I-693, and form instructions. Officers do not need to verify whether the civil surgeon instructed the referring physician to check the applicant’s identity.


An officer should follow the chart below to determine whether the applicant or a legal guardian must sign the form.[18] See 8 CFR 103.2(a)(2). 


Signature of the Applicant

Age of Applicant

Signature Requirement


Age 14 or Older

The applicant must sign Form I-693. However, a legal guardian may sign for a mentally incompetent person.


Under Age 14

Either the applicant, a parent, or legal guardian may sign the Form I-693. The officer should not reject the form as improperly completed if only the applicant, parent, or guardian signs.



Signature of Physicians Receiving Referrals for Evaluation


If the civil surgeon is unable to perform a particular medical assessment, he or she is required to refer the applicant to another physician. The physician receiving the referral is required to complete the appropriate section on Form I-693 after he or she has completed the evaluation of the applicant’s condition. The civil surgeon may not sign the civil surgeon’s certification on the form until the civil surgeon has received and reviewed the report of the physician who received the referral. If the referring physician ordered treatment, the civil surgeon may not sign the certification until the treatment has been completed.


Contracted services used by the civil surgeon to complete a step in the medical examination are not considered referrals. Therefore, the referral section can be blank in such cases.[19] Civil surgeons are, however, still responsible for ensuring that the contractor properly checks the applicant’s ID.  For example, if the civil surgeon uses a contractor to draw blood, the referral section does not have to be completed. However, if the Technical Instructions require a referral to the Health Department because the applicant has TB, the officer must make sure that the referral section is completed.


4. Validity Period of Form I-693 (Including Use of Prior Versions)


Evidentiary Value


A person seeking an immigration benefit and who is subject to medical grounds of inadmissibility must establish that he or she is not inadmissible on medical grounds.[20] See INA 212(a)(1). In general, those applying for immigration benefits while in the United States must use Form I-693 to show they are free from any conditions that would render them inadmissible. 


An officer may determine that the applicant has met the burden of proof required to establish that he or she is free from a medical condition that would render the applicant inadmissible if all of the following criteria are met:



In general, if any one of the above criteria is not met, the applicant has not met the burden of proof required to establish that he or she is free of a medical condition that would render him or her inadmissible to the United States. In this case, the officer should follow standard operating procedures regarding issuance of an RFE or Notice of Intent to Deny (NOID) to address the deficiency. 


Special rules may apply to certain foreign nationals who were examined overseas, including certain nonimmigrant fiancé(e)s or spouses of U.S. citizens (K visa), spouses of lawful permanent residents (V visa), refugees, and asylee dependents. Such foreign nationals usually do not need to repeat the full medical exam in the United States for purposes of adjustment of status.[26] See Chapter 3, Applicability of Medical Examination and Vaccination Requirement [8 USCIS-PM B.3] for more information on these special considerations. 


Generally, the only acceptable version of Form I-693 is the version in use at the time of the medical examination. Prior versions of Form I-693 are generally not acceptable because they may lack necessary information.[27] See http://www.uscis.gov/i-693 for the current and accepted version(s) of the form.


Timing of the Submission of the Medical Examination Report


The medical examination report may be submitted to USCIS:


  • Concurrently with the immigration benefit application; or


 

Place of Submission of the Medical Examination Report


The medical examination report should be submitted to the appropriate location.[29] See http://www.uscis.gov/i-693 for location information.





Footnotes


1. [^] 

 As of October 1, 2013, panel physicians only use DS-2054. The DS-2053 is no longer used after that date.

2. [^] 

 The Technical Instructions for Panel Physicians may differ from the Technical Instructions for Civil Surgeons. As long as the DS form is properly completed, the officer should accept the finding of the consular officer as correct.

3. [^] 

 In this case, because the DS form was completed by a panel physician, the officer should retain the original document. The RFE must specify which sections of Form I-693 have to be completed by a civil surgeon.

4. [^] 

 See Chapter 3, Applicability of Medical Examination and Vaccination Requirement [8 USCIS-PM B.3] for specific information on who is required to be examined and to what extent.

5. [^] 

 Form I-693 can only be used for immigration benefits that are granted in the United States.

6. [^] 

 See INA 232 and 8 CFR 232.

7. [^] 

 Some parts of the form may not be required. For example, if an applicant is not required to undergo a chest X-ray in the TB section of the medical examination report, the chest X-ray section would not have to be completed.

8. [^] 

 See Subsection 3, Signatures [8 USCIS-PM B.4(C)(3)].

9. [^] 

 See Subsection 3, Signatures [8 USCIS-PM B.4(C)(3)].

10. [^] 

 See Subsection 3, Signatures [8 USCIS-PM B.4(C)(3)].

11. [^] 

 See Subsection 4, Validity Period of Form I-693 (Including Use of Prior Versions) [8 USCIS-PM B.4(C)(4)].

12. [^] 

As part of completing the Form I-693, the civil surgeon must ensure that the applicant has signed the applicant’s certification.

13. [^] 

 Along with the original Form I-693, if separate from the corrected form. 

14. [^] 

 See Volume 9, Waivers, Part C, Waivers for Health-Related Grounds of Inadmissibility [9 USCIS-PM C] for more on waivers.

15. [^] 

 See Part C, Civil Surgeon Designation and Revocation [8 USCIS-PM C] for more information on the blanket civil surgeon designation for health departments.

16. [^] 

 See Part C, Civil Surgeon Designation and Revocation [8 USCIS-PM Cfor more information on the blanket civil surgeon designation for military physicians.

17. [^] 

 By signing the form, the civil surgeon certifies that he or she has examined the applicant according to the procedures and requirements outlined in the Technical Instructions, Form I-693, and form instructions. Officers do not need to verify whether the civil surgeon instructed the referring physician to check the applicant’s identity.

18. [^] 

 See 8 CFR 103.2(a)(2). 

19. [^] 

 Civil surgeons are, however, still responsible for ensuring that the contractor properly checks the applicant’s ID. 

20. [^] 

 See INA 212(a)(1).

21. [^] 

 See Section C, Documentation Completed by Civil Surgeon [8 USCIS-PM B.4(C)]. 

22. [^] 

 USCIS will use the date the Form I-693 was signed by the civil surgeon (including blanket-designated health departments and military physicians) to determine whether the report was submitted less than one year after completion of the examination.

23. [^] 

 For example, an Application to Register Permanent Residence or Adjust Status (Form I-485).

24. [^] 

 USCIS will use the date that USCIS received the Form I-693 to determine whether the medical examination report is more than one year old at time of adjudication of the benefit application. Although the medical examination report is generally valid for adjudicatory purposes up to one year after filing, the officer may order an additional immigration medical examination at any time if he or she has concerns as to an applicant’s inadmissibility on health-related grounds. For more information, see Chapter 11, Inadmissibility Determination, Section C, Other Information [8 USCIS-PM B.11(C)].

25. [^] 

 For more information on determining inadmissibility based on medical grounds, see Chapter 5, Review of Overall Findings [8 USCIS-PM B.5] through Chapter 11, Inadmissibility Determination [8 USCIS-PM B.11].

26. [^] 

 See Chapter 3, Applicability of Medical Examination and Vaccination Requirement [8 USCIS-PM B.3] for more information on these special considerations.

27. [^] 

 See http://www.uscis.gov/i-693 for the current and accepted version(s) of the form.

28. [^] 

 This includes a request to bring the medical examination report to the interview.

29. [^] 

 See http://www.uscis.gov/i-693 for location information.




Updates


Date Details
May 30, 2014
POLICY ALERT

Validity Period of the Medical Certification on the Report of Medical Examination and Vaccination Record (Form I-693)

U.S. Citizenship and Immigration Services (USCIS) is issuing an update to policy guidance in the USCIS Policy Manual addressing the validity period of civil surgeon endorsements on the Report of Medical Examination and Vaccination Record, Form I-693.

Read more »

January 28, 2014
POLICY ALERT

Health-Related Grounds of Inadmissibility and Waivers

​U.S. Citizenship and Immigration Services (USCIS) is issuing guidance in the USCIS Policy Manual on the health-related grounds of inadmissibility under INA 212(a)(1) and corresponding waivers under INA 212(g).

Read more »


Current as of July 1, 2014