U.S. Citizenship and Immigration Services, or USCIS, announced its long-awaited revisions to Form N-648, or Medical Certification for Disability Exceptions, on Oct. 19, 2022, along with major changes to the USCIS Policy Manual guidance that will align it with the new form. The new edition is dated Aug. 19, 2022. Starting on Nov. 21, 2022, USCIS will only accept the new edition. Until then, USCIS will continue to accept the previous edition, dated July 23, 2020.

The new Form N-648 is almost identical to the proposed version we reviewed and commented on in November 2021. At that time, we expressed our support for nearly all the changes and urged USCIS to implement the proposed changes as soon as possible, and to update the policy guidance to concur with the new form. Below is a list of key changes in the new Form N-648:

• The new Form N-648 is much shorter and has been cut in half from the previous version, from 9 pages to 4.5 pages.
• Part 1, Applicant Information, has been shortened. The new form no longer requests the applicant’s Social Security Number or address.
• The number of questions in Part 3, Information About Disabilities and/or Impairments, has been greatly reduced and simplified to just key information. In particular, the question about the applicant’s daily life activities in the previous version has been deleted. The following questions have also been deleted: questions about the description of the disabilities, cause of the disabilities, dates of diagnosis, dates of onset, date/location the doctor first examined the applicant, frequency of treatment, if the doctor is the one who regularly treats the applicant, duration of treatment, name of regularly treating medical professional, and explanation of why this doctor is certifying the form instead of the regularly treating medical professional.
• Also in Part 3, the previous questions about the clinical diagnosis and the connection between the disability/impairment and inability to meet the testing requirements have been combined in the first question.
• A new section has been added: Part 4, Ability to Understand Oath of Allegiance, in which the medical professional is asked if the applicant is able to understand and communicate an understanding of the oath. In our earlier comments, we asked USCIS to remove this question from the form. The USCIS Policy Alert explains that the intent of this question is to streamline the oath waiver process by eliminating the need for a separate oath waiver request. However, we are concerned that this question will trigger a big increase in unnecessary oath waiver requests. Most doctors will not understand the oath requirements and will indicate that the applicant requires an oath waiver. Then, the applicant will need a legal guardian, a surrogate, or a designated representative who is a U.S. citizen to testify on their behalf, creating another barrier for those who cannot easily meet this requirement. CLINIC plans to raise these concerns with USCIS and request additional training for medical professionals and adjudicators on the oath waiver. In the meantime, advocates will need to work closely with the medical professional to ensure they answer “yes” if the applicant is capable of taking the oath.
• Part 5, Interpreter Information and Certification, distinguishes between in-person interpretation and telephonic interpretation and has clear instructions on how to complete this section when a telephonic interpreter was used.
• In Part 6, Applicant’s (Patient’s) Attestation/Release of Information, the signature box notes that an applicant can make a mark if they are unable to sign. This is something we requested in our comments.
• Part 7, Medical Professional’s Certification, has been simplified, with key information enumerated at the beginning.
• The Form N-648 Instructions have added information on how to file the N-648 when submitting the N-400 electronically, stating that it can be uploaded as additional evidence. In addition, the instructions have added information to clarify that a legal guardian, surrogate, or designated representative may sign for an applicant who has been deemed legally incompetent.

The USCIS Policy Manual guidance on disability waivers has undergone major revisions that make it consistent with the substance and spirit of the new Form N-648. While the previous version of the policy guidance was harsh and punitive, the new guidance is much more humane and offers more flexibility for applicants in meeting the N-648 requirements. Key changes are discussed below.

Flexibility on N-648 filing date and supplemental information

The new guidance states that while the N-648 should be submitted as an attachment to Form N-400, “USCIS should accept a Form N-648 submitted after the applicant files the naturalization application” with none of the strict conditions imposed by the previous guidance (Part B).

If the first N-648 is not sufficient, the applicant can submit an updated form with additional information rather than a new N-648. “The resubmitted form must be signed and dated by the same medical professional who signed the original Form N-648” and will be accepted even if the form edition is now expired and no longer in use. “USCIS will also accept a letter or other medical documentation addressing the Form N-648 deficiencies, if it is signed and dated by the same medical professional who signed the Form N-648” (Part G, Section 2).

Flexibility in determining when Form N-648 is sufficient

While the previous guidance required that every question on the Form N-648 be answered fully, the new guidance provides a lot more flexibility. The guidance states that “an officer reviews the Form N-648 in its totality” and an officer reviewing the Form N-64 may determine that it is sufficient “even if some of the questions have incomplete responses… if the file and testimony establish that the applicant is eligible” (Part G).

If information is missing from the N-648, the guidance states that “the officer should review any extra documents provided by the medical professional to determine if the information completes the Form N-648” (Part E). In addition, the guidance states, “Before determining that a Form N-648 is insufficient due to missing information, officers should review all sections to confirm that the information needed does not appear in a different section of the form” (Footnote 24). The N-648 may not be found insufficient solely because Diagnostical and Statistical Manual of Mental Disorders (DSM) or International Classification of Diseases (ICD) codes are missing “if the medical professional has provided a sufficient description of the clinical diagnosis” (Footnote 20). Similarly, the officer “should not determine that the form is insufficient solely because the date of last examination is missing on the form if the date can be confirmed during the naturalization interview.” (Footnote 21). If their signatures are missing on the form, the officer may allow the applicant or the interpreter to sign the form at the interview (if the interpreter was the same one used during the medical professional’s examination) (Footnote 13).

Limited reasons for credible doubt

The list of examples of credible reasons to doubt the validity of the form in Part F, Section 4 has been shortened quite a bit and includes, for example, “The medical professional who completed the Form N-648 is under investigation for immigration fraud, Medicaid fraud, or other fraud schemes.” However, it is still open to a lot of interpretation by adjudicators and includes the catch-all example of “Any other articulable grounds that are supported by the record.” Providing multiple N-648s with different diagnoses and information remains a credible reason to doubt the validity of the Form N-648 in the new guidance, so legal advocates still need to review N-648s carefully for consistency when the client has more than one. In two places, the new guidance states that “in general, USCIS should accept the medical professional’s diagnosis” (Part F, Section 4 and Part G).

While the previous guidance emphasized that the regularly treating medical professional should complete Form N-648, this emphasis has been removed from the new guidance. In the past, if the form was completed by a different medical professional and lacked a sufficient explanation of why, this could be cause for credible doubt and lead to a denial.

Telehealth examination

In Part E, the new policy guidance states that USCIS may accept a Form N-648 certified by a licensed medical professional who completed a telehealth exam. The medical professional must adhere to their state telehealth laws and requirements.

Increased transparency and communication with the applicant

The new guidance appears to improve transparency and communication with the applicant regarding the sufficiency of Form N-648. For example, if an applicant submits more than one N-648 and there are significant discrepancies between the documents, “the officer must provide the applicant with an opportunity to explain discrepancies” (Part B, Section 2). Later, it states again, “The officer must provide the applicant an opportunity to address any specific discrepancies or inconsistencies during the interview” (Part 4, Section F). If the form is insufficient, “The officer must explain why they found the form insufficient in the applicant’s preferred language, using an interpreter if needed” (Part G, Section 2). This is stated again in Part H, Section 2: “The officer must explain the reasons for insufficiency in the applicant’s preferred language verbally during the interview, using an interpreter if needed.” Before requesting a supplemental Form N-648, the officer must seek supervisory approval and “Explain to the applicant, through an RFE, the reasons for doubting the veracity of the information on the original Form N-648.” (Part F, Section 4).

This is not a complete list of all the changes in the new policy guidance. Affiliates who are assisting a client with a disability waiver are urged to read the new guidance in its entirety and reach out to CLINIC with any questions. Overall, the new Form N-648 and disability waiver policy guidance is a major step in the right direction that will improve access to naturalization for people with disabilities, after so many years of increasing length, complexity, and barriers in the form and guidance.

USCIS will hold a stakeholder engagement on the new Form N-648 and policy guidance on Tuesday, Nov. 1, 2022, 2 – 3 p.m. EST. For more information and to register, click here: https://www.uscis.gov/outreach/upcoming-national-engagements/uscis-stakeholder-engagement-form-n-648-medical-certification-for-disability-exceptions.