Chapter 3 - Medical Disability Exception (Form N-648)
In 1994, Congress enacted legislation providing an exception to the English and civics requirements for naturalization applicants who cannot meet the requirements  because of a physical or developmental disability or mental impairment. 
The English and civics requirements do not apply to naturalization applicants who are unable to comply due to a “medically determinable” physical or developmental disability or mental impairment that has lasted, or is expected to last, at least 12 months. The regulations define medically determinable as an impairment that results from abnormalities which can be shown by medically acceptable clinical or laboratory diagnostic techniques. 
The applicant has the burden of proof, by a preponderance of the evidence standard, to demonstrate that he or she has a disability or impairment that affects functioning such that, even with reasonable accommodations, he or she is unable to meet the English and civics requirements for naturalization. Illiteracy alone is not a valid reason to seek an exception to the English and civics requirements. In addition, advanced age, in and of itself, is not a medically determinable physical or developmental disability or mental impairment.
A licensed medical professional  must complete the form and certify, under penalty of perjury, that the applicant’s medical condition prevents the applicant from meeting the English requirement, the civics requirement, or both requirements.
An applicant seeking an exception to the English and civics requirements must submit a Medical Certification for Disability Exceptions (Form N-648) as an attachment to the Application for Naturalization (Form N-400).  USCIS generally only considers a Form N-648 that is concurrently filed with a Form N-400 to be filed timely, but later-filed or multiple Forms N-648 may be accepted in certain circumstances as set forth below.
USCIS may consider a later-filed Form N-648 if the applicant provides a credible explanation for filing the N-648 after filing the Form N-400 and submits sufficient evidence in support of that explanation. For example, if a significant change in the applicant’s medical condition since the submission of the initial Form N-648 has taken place, a later-filed Form N-648 would be appropriate. Other explanations for not filing the Form N-648 with the initial Form N-400 may also be acceptable, and an officer should consult with his or her supervisor and USCIS counsel in those cases.
The officer should review the explanation and documentation carefully, because without sufficient probative evidence, a late submission can raise credible doubts about the validity of the medical certification, especially where little or no effort is made to explain the delay, and the applicant claims that the stated disability or impairment was present before the naturalization application was filed.  USCIS may require the submission of an additional Form N-648 or refer the applicant to another medical professional for a supplemental disability determination or completion of a new Form N-648, if there are credible doubts as to the veracity of the medical certification.
If multiple Forms N-648 are submitted at the same time, an officer should question the applicant about the reasons for any additional Forms N-648, and carefully examine any discrepancies between the documents. Two different Forms N-648 from different medical professionals may also raise questions of credibility about the validity of the medical certification. Significant discrepancies may be a basis for finding the Form N-648 insufficient. In the absence of a reasonable justification, multiple submissions may raise credible doubts about the validity of the medical certification, especially where the stated disability or impairment was not identified or discussed earlier.  USCIS may require the submission of an additional Form N-648 or refer the applicant to another medical professional for a supplemental disability determination or completion of a new Form N-648 if there are credible doubts as to the veracity of the medical certification.
Properly Filed Medical Certification for Disability Exceptions (Form N-648)
Completed, certified, and signed by all appropriate parties.
In addition, the medical certification must contain the following information:
Requesting an exception to the English and civics requirements is different from requesting an accommodation for the naturalization examination process.  An approved exception exempts the applicant from the English requirement, the civics requirement, or both requirements completely or partially, depending on the facts of the specific case. An accommodation, on the other hand, simply modifies the manner in which an applicant meets the educational requirements; it does not exempt the applicant from the English or civics requirements.
Reasonable accommodations may include, but are not limited to, sign language interpreters, extended time for completing the English and civics requirements, and completing the English and civics requirements at an off-site location. A disability exception requires an applicant to show that his or her medical condition prevents the applicant from complying with the English or civics requirements or both, even with reasonable accommodations. The impact of a particular medical condition may vary between individual cases. It may be possible to accommodate one applicant who is affected by a particular medical condition, while another applicant affected by the same condition may be eligible for a disability exception. For example, someone who is visually impaired may require the accommodation of a large print version of the reading test in order to complete the requirement. However, if a person is not able to read because of the medical condition even with an accommodation, then the person needs to file a Form N-648. In such cases, where an accommodation is insufficient, USCIS may accept a later filed Form N-648.
USCIS only authorizes the following licensed medical professionals to certify the disability exception form:
Doctors of osteopathy; and
Clinical psychologists. 
These medical professionals must be licensed to practice in any state of the United States, the District of Columbia, Puerto Rico, Guam, the Virgin Islands of the United States, or the Commonwealth of the Northern Mariana Islands.
The medical professional must, at a minimum:
Conduct at least one in-person examination of the applicant;
Explain the nature and extent of the medical condition on Form N-648;
Explain how the medical condition relates to the applicant’s inability to comply with the educational requirements;
Attest that the medical condition has lasted or is expected to last at least 12 months; and
Attest that the cause of the medical condition is not related to the illegal use of drugs.
The medical professional must complete the Form N-648 using common terminology that a person without medical training can understand. While staff associated with the medical professional may assist in completing the form, the medical professional alone is responsible for providing the necessary information, answering the questions, and verifying and attesting to the accuracy of the form’s content.
The medical professional certifying the form may choose to provide medical diagnostic reports, records, and statements as attachments to the Form N-648 as evidence of the disability. Any supporting documentation should be clearly probative of the medical disability that prevents the applicant from completing the required English and civics requirements.
Failure to correctly fill out each question with the appropriate, corresponding responses may result in a finding that the Form N-648 is insufficient.
The officer must carefully review the form to determine whether the applicant is eligible for the exception. The table below provides general guidelines on what steps the officer should and should not take when reviewing the Form N-648.
When reviewing the form, the officer should:
When reviewing the form, the officer should not:
In reviewing the request for the medical disability exception, the officer must focus on whether the medical professional has sufficiently explained with enough supporting details that the applicant has a disability or impairment and its nature. The medical professional must also explain how the applicant's disability or impairment prohibits the applicant from being able to demonstrate the English or civics requirements or both. The explanation should be sufficiently detailed and tailored to the individual applicant’s diagnosed medical disabilities or impairment.
After review of the record, the officer may only grant an exception if the applicant has demonstrated by a preponderance of the evidence that there is a nexus (or causal connection) between the disability or impairment and:
The applicant’s inability to read, write, and speak words in ordinary usage in the English language;
The applicant’s inability to know and understand the fundamentals of history and of the principal form of government of the United States; or
Form N-648 requires the medical professional to describe the severity of the effects of the medical condition on the applicant’s daily life. The medical professional must explain the basis of his or her assessment, such as known symptoms of the condition, tests conducted, and observations. The officer can question the applicant during the naturalization interview about the applicant’s daily life activities. If discrepancies exist regarding the applicant’s daily life and activities between the naturalization applicationand information contained in the A-file, the Form N-648 itself, or from any other source of information, the officer should question the applicant during the interview about those discrepancies.
Certification on Form N-648 and Presence of Interpreter at Medical Examination
If it is unclear whether an interpreter was used during the medical examination, the officer must ask the applicant whether the medical examination that formed the basis of the Form N-648 was performed with the assistance of an interpreter.
For example, the officer may question the applicant during the interview:
About the applicant’s visits with the medical professional and the nature of their relationship.
About the manner of communication used to conduct the medical examination.
If an interpreter was used during the medical examination but the interpreter’s certification on the Form N-648 is blank, the form is considered incomplete. The officer must then provide the applicant with notice of the deficiency and an opportunity to bring a properly completed Form N-648 to the re-examination.
If necessary, the officer may also choose to subpoena and question the interpreter, if any, who was present at the medical examination about their translations during a medical examination in connection with the applicant’s Form N-648. If the officer wishes to question an interpreter he or she must be under the general oath. If the person who interpreted at the medical examination is the same person as the person interpreting at the naturalization interview, the interpreter must then be disqualified from interpreting for that applicant going forward.  In this case, the officer should reschedule the interview, as needed, to permit the applicant an opportunity to find a new interpreter.
Interpreter at Interview
During the interview, the officer should question the applicant under oath in the applicant’s preferred language, with use of an interpreter,  if needed, to address any issues of concern related to the Form N-648. In the agency’s discretion, and in all cases, the officer may also disqualify an interpreter provided by the applicant for cause and reschedule the interview.  If the office has a language service available, the officer may use the language service when the interpreter is disqualified.
In general, USCIS does not request a supplemental disability determination from another doctor after evaluating the originally submitted Form N-648. However, if there is a question as to whether the medical professional actually examined and diagnosed the applicant or there are credible doubts as to the veracity of the medical certification because it is clearly contradicted by other evidence, the officer may request a new Form N-648 from a different doctor. The officer should exercise caution when requesting an applicant obtain a supplemental disability determination from another authorized medical professional. The officer should:
Explain the reasons for doubting the veracity of the information on the original Form N-648, to include any observations or applicant responses to questions during the interview that raised issues of credible doubt or sworn statements submitted at the time of the interview;
Consult with a supervisor and receive approval before requesting that the applicant undergo a supplemental disability determination; and
Provide the applicant with the relevant state medical board contact information to facilitate the applicant’s ability to find another medical professional.
In general, USCIS should accept the medical professional’s diagnosis. However, an officer may find a Form N-648 insufficient if there is a finding of credible doubt, discrepancies, misrepresentation or fraud as to the applicant’s eligibility for the disability exception.
The officer must provide the applicant an opportunity to address any specific discrepancies or inconsistencies during the interview. When issuing a request for evidence, the officer should only request the information necessary to make a determination on the sufficiency of the Form N-648. In some cases, USCIS may require the submission of an additional Form N-648 or request the applicant's medical reports or other supplementary medical background information if there is a question whether the medical professional actually examined and diagnosed the applicant or there are credible doubts as to the veracity of the medical certification because it is clearly contradicted by other evidence.
The medical professional’s responses on the Form N-648 lack probative value because the responses do not contain a reasonable degree of detail or fail to provide any basis for the stated diagnosis and the nexus to the inability to learn, speak or read or understand English;
The medical professional did not explain the specific medical, clinical, or laboratory diagnostic techniques used in diagnosing the applicant’s medical condition on the Form N-648;
The Form N-648 does not include an explanation of the doctor-patient relationship indicating that the medical professional completing the Form N-648 regularly treats the applicant for the cited conditions, or a reasonable justification for not having the Form N-648 completed by the regularly treating medical professional (if applicable);
The Form N-648 was completed by the certifying medical professional more than 6 months prior to the filing of the naturalization application;
The Form N-648 provides information inconsistent with information provided on the naturalization application or at the interview. For example, the effects of the medical condition on the applicant’s daily life such as employment capabilities or ability to attend educational programs;
Previous medicals including Report of Medical Examination and Vaccination Record, Form I-693 did not identify long-term medical condition which may be inconsistent with the Form N-648’s indication of when the condition began, if indicated;
The applicant or the medical professional failed to provide a reasonable justification for the late filing of the Form N-648;
The applicant during the interview indicates that he or she was not examined or diagnosed by the medical professional, the medical professional did not certify the form him or herself, or the applicant merely paid for the Form N-648 without a doctor’s examination and diagnosis;
The medical professional completing the Form N-648 is under investigation for immigration fraud, Medicaid fraud, or other fraud schemes by USCIS Fraud Detection and National Security (FDNS) Directorate, Immigration and Customs Enforcement, or another federal, state, or local agency, or a state medical board;
The medical professional has engaged in a pattern of submitting Forms N-648 with similar or “boiler plate” language that does not reflect a case-specific analysis;
The interpreter used during the medical examination, the N-400 interview, or both, is known or suspected, by FDNS or another state or federal agency, to be involved in any immigration fraud, including and especially Form N-648 related fraud;
The evidence in the record or other credible information available to the officer indicates fraud or misrepresentation;
The applicant provides multiple Forms N-648 with different diagnoses and information and from different doctors; or
Any other articulable grounds that are supported by the record.
If any one or more of these indicators are present, the officer should consult with his or her supervisor for next steps, which may include requesting additional documentation or finding the Form N-648 insufficient.
In addition, there may be cases where USCIS suspects or determines that an applicant, interpreter, or medical professional has committed fraud in the process of seeking a medical disability exception. The officer should consult with his or her supervisor to determine whether to refer such a case to FDNS. If an officer or the local FDNS office determines that an applicant, interpreter, or medical professional has made material misrepresentations or committed fraud, the officer must explain those findings in thenaturalization denial notice.
The officer should determine that a request for a medical disability exception is insufficient if:
The Form N-648 is not properly completed;
The medical professional fails to explain how the applicant’s medical condition prohibits the applicant from meeting the English requirement, the civics requirement, or both requirements;
The medical professional who certified the Form N-648 is not authorized to make such certification; 
The applicant was not examined or diagnosed by the certifying medical professional;
The applicant described in the Form N-648 is not the same person as the naturalization applicant;
The Form N-648 was completed or certified by someone other than the certifying medical professional; or
Significant anomalies, discrepancies, or fraud indicators exist that preclude a finding of eligibility under a preponderance of the evidence standard.
The table below provides the general procedures for finding the Form N-648 to be insufficient. The procedures apply to any phase of the naturalization examination, including the initial examination, re-examination, or hearing on a denial.
If the Form N-648 is insufficient at the naturalization examination or hearing:
Passing the English and Civics Requirements 
If an applicant’s Form N-648 is found to be insufficient, but the applicant subsequently meets the English and civics requirements in the same examination:
The officer must provide the applicant the opportunity to proceed with the naturalization examination to determine if the applicant meets the other applicable eligibility requirements.
The officer should not determine that the applicant engaged in fraud or lacks good moral character for the sole reason that the applicant met the educational requirements after submitting an insufficient Form N-648.
The officer may question the applicant further, however, on the reasons for submitting the form, the applicant’s relationship to the medical professional, and any other relevant factors, if deemed necessary.
Failing the English and Civics Requirements
If an applicant’s Form N-648 is found to be insufficient, and the applicant fails to meet the English and civics requirements:
The officer must notify the applicant of the Form N-648 deficiencies in writing. USCIS may choose to issue the applicant a request for evidence that specifically addresses the issues with the Form N-648.
The officer should schedule the applicant to appear for a re-examination, and for a second opportunity to meet the English and civics requirements, between 60 and 90 days after the initial examination.
If new information is received in support of a Form N-648 that USCIS found insufficient at the initial interview, the officer must review the evidence at the re-examination. In addition, the officer conducting the re-examination should review the original Form N-648 and accompanying evidence for consistency with the new information.
If an applicant submits a Form N-648 for the first time at the re-examination interview, the officer should carefully question the applicant as to why he or she did not submit the Form N-648 at the time of filing the naturalization application as required by the regulations, or at the initial interview.
The officer should follow the same procedure and apply the same criteria during the re-examination regarding late or multiple Form N-648 submissions. The officer should carefully consider whether there is any evidence of change in medical conditions or other credible explanation justifying the initial submission of the Form N-648 at the re-examination. The officer should then weigh the explanation and evidence provided by the applicant regarding the late filing. USCIS may consider the timing of the filing and any additional Form N-648s submitted by the applicant when assessing the applicant’s credibility with regard to the disability exception.
If the applicant has established that he or she is eligible for the disability exception, the officer should then allow the naturalization interview and examination to continue with the use of an interpreter, if applicable, exempting the applicant from the English or civics requirements, or both, as indicated on the form.
If, on the other hand, the applicant does not provide sufficient evidence that the late submission is due to a material change in his or her medical condition, or does not provide another credible explanation, the applicant may not be eligible for the disability exception. If the officer determines for any reason that the Form N-648 is insufficient to establish eligibility for the disability waiver, the officer may not grant the exception but should afford the applicant a second opportunity to take the English and civics tests.
If the applicant fails any portion of the test or declines to continue with the re-examination, the officer must deny the naturalization application based on the applicant’s failure to meet the English and civics requirements. In the naturalization denial notice, the officer must provide an explanation for finding the form insufficient to show eligibility for the disability exception.
If the officer issued a request for evidence at the initial interview and determines that the evidence submitted in response to the request for evidence is insufficient:
The officer must proceed with the re-examination as if the applicant had not submitted a Form N-648;
The officer must provide the applicant with a second opportunity prior to adjudication to take any portion of the English and civics tests that the applicant previously failed;
The officer must not provide the applicant a third opportunity to submit a Form N-648 or to take the English and civics tests;
If the applicant fails any portion of the testing, including declining the test or failing to respond to test questions correctly, the officer must deny the naturalization application based on the applicant’s failure to meet the English and civics requirements; and
The officer must provide an explanation of the Form N-648’s deficiencies in the naturalization application’s denial notice.
All denied naturalization applicants may file a Request for a Hearing on a Decision in Naturalization Proceedings (Under Section 336 of the INA) (Form N-336) within 30 calendar days of receiving the adverse decision. 
USCIS may conduct a full de novo hearing on a denied naturalization application, including a full review of any previously submitted Form N-648 as well as other information contained in the record.  An applicant may submit additional documentation at the hearing, including a new or initial Form N-648 and relevant medical diagnostic reports, records, or statements. Although an applicant may submit a Form N-648 for the first time during a hearing, the officer may question the credibility of the N-648 as described above. At the hearing, an applicant will only be allowed to submit one Form N-648 and only allowed to attempt to satisfy the educational requirements once.
In addition, the officer also should follow the same procedures in the hearing as provided in this chapter when making a determination that a Form N-648 filed for the first time at the hearing is sufficient or insufficient.
The officer should determine that a request for a medical disability exception is sufficient if, at a minimum:
The Form N-648 is properly completed per the form instructions;
The medical professional explains in detail how the applicant’s medical condition prevents the applicant from meeting the English requirement, the civics requirement, or both requirements; and
No anomalies, discrepancies, or fraud indicators exist, based on the totality of evidence of record, that call into question a finding of eligibility under a preponderance of the evidence standard.
The table below provides the general procedures for cases where an applicant qualifies for a disability exception. The procedures apply to any phase of the naturalization examination, including the initial examination or re-examination, or hearing on a denial.
If the officer determines an applicant’s Form N-648 is sufficient at the naturalization examination or hearing:
1. [^] The term “English and civic requirements” refers to demonstrating English language proficiency, which is determined by an ability to read, write,speak, and understand English, as well as knowledge of U.S. history and government, which is determined by a civics test. See Chapter 2, English and Civics Testing, Section A, Educational Requirements [12 USCIS-PM E.2(A)].
6. [^] For more information about credible doubt, see Section E, Review of Medical Certification for Sufficiency, Subsection 5, Credible Doubt, Discrepancies, Misrepresentation, and Fraud [12 USCIS-PM E.3(E)(5)].
8. [^] See 45 CFR 162.1002. The relevant medical codes, if any, are required to ensure the medical professional provides his or her medical opinion with a certain level of specificity. The codes should not be used by officers to attempt to determine the validity of the medical diagnosis or second-guess why the diagnosis precludes the applicant from complying with the educational requirements.
11. [^] However, in the officer’s discretion, a “good cause” exception may be granted that would allow the witness to interpret. See Adjudicator’s Field Manual (AFM) Chapter 15.7, The Role and Use of Interpreters in Domestic Field Office Interviews without USCIS-Provided Interpretation.
12. [^] The interpreter must be under oath. See Adjudicator’s Field Manual (AFM) Chapter 15.7, The Role and Use of Interpreters in Domestic Field Office Interviews without USCIS-Provided Interpretation.
14. [^] The list provided is not exhaustive and is meant only to provide some examples for officers when reviewing Form N-648 sufficiency. Officers should consult with their supervisor if there are any questions.
16. [^] An officer should annotate that the applicant declined to take any part of the educational requirements in the record.
No appendices available at this time.
Technical Update - Implementation of Policy Guidance on Medical Certification for Disability Exceptions (Form N-648)February 12, 2019
This technical update incorporates into Volume 12 the policy guidance that U.S. Citizenship and Immigration Services announced December 12, 2018 regarding the Medical Certification for Disability Exceptions (Form N-648). This guidance became effective February 12, 2019.
POLICY ALERT - Sufficiency of Medical Certification for Disability Exceptions (Form N-648)December 12, 2018
U.S. Citizenship and Immigration Services (USCIS) is issuing policy guidance in the USCIS Policy Manual to update and clarify filing procedures and adjudications on the Medical Certification for Disability Exceptions (Form N-648). This guidance becomes effective February 12, 2019.
Technical Update - Medical Codes for Purposes of Medical Certification for Disability ExceptionsJanuary 05, 2017
This technical update clarifies that, for purposes of Form N-648, Medical Certification for Disability Exceptions, USCIS accepts the relevant medical codes recognized by the Department of Health and Human Services. This includes codes found in the Diagnostic and Statistical Manual of Mental Disorders and the International Classification of Diseases.
POLICY ALERT - Comprehensive Citizenship and Naturalization Policy GuidanceJanuary 07, 2013
USCIS is issuing updated and comprehensive citizenship and naturalization policy guidance in the new USCIS Policy Manual.