Immigration Medical Questionnaire

Complete this form at least 24 hours prior to your appointment

Please correct the errors described below.

Please fill in all information exactly as you want it to appear on your USCIS Form I-693 Medical Exam

Personal Information

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    Immigration Information

    This is a nine digit number that USCIS assigns to your submitted adjustment of status application. It appears on most correspondence sent to you by USCIS and starts with the letter "A". For example: A219-304-659. If you have an employment authorization card, it is listed as "USCIS #" without the letter A. For example: 219-304-659.

    Interpreter Information

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    Medical/Social Information

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        Other Information

        Office Policies

        Legal Relationship

        Although civil surgeons are fully licensed medical professionals, an immigration medical exam does NOT constitute engagement in a patient-doctor relationship. The civil surgeon is solely responsible for the examination of your health status and, when applicable, the treatment of communicable diseases in the manner outlined by the USCIS technical instructions and bears no responsibility to diagnose or treat other health conditions that you may have.

        Medical Records

        Upon completion of the immigration medical exam, we will provide your original Form I-693 in a sealed envelope. Do not open this envelope or your paperwork will be considered invalid. Per USCIS guidelines, we will also provide you with a photocopy of your Form I-693. If you need to obtain another copy your medical records at any point in the future, please call our client service line.

        Requests for Evidence

        If you receive a Request for Evidence (RFE) letter from the USCIS in response to a Form I-693 completed in our office, please contact us immediately so that we can resolve any deficiencies in your immigration paperwork. There will be no additional charge for this service provided we are able to determine that the RFE was generated in response to an oversight on the part of the civil surgeon or our office staff.

        Health Insurance

        Although our office does not hold any health insurance contracts, we may still be able to forward your insurance information to our laboratory, Quest Diagnostics, and/or our vaccine supplier, VaxCare, so that they can bill your health insurance company. In instances when this is possible and you affirm in-advance that you would like to use your insurance coverage for this purpose, our office will deduct the cost of the corresponding vaccination(s) and/or laboratory test(s) from your invoice. Our clinic and staff assume no liability for the outcome of any coverage and/or payment determinations made by your health insurance company. We suggest that you contact your insurance company prior to your visit to find out about your plan's specific benefits. If requested, our office will provide a list of service and diagnosis codes which may assist your insurance company in providing you with accurate benefits and coverage information.

        Filing Deadline

        It is your responsibility to ensure that you meet any filing deadlines. Adjustment of status applicants who have not yet submitted their underlying benefit application prior to completing the immigration medical examination must submit Form I-693 to USCIS within 60 days of the civil surgeon signing it. Our office will “update” and reprint a client’s Form I-693 for $50 provided that not more than 90 days has passed since the original signature date. Once that time has elapsed, you will be required to undergo and pay for an entirely new medical exam.

        Adverse Reactions

        If you feel that you are experiencing a serious allergic reaction due to a vaccination which was administered in the office, we ask that you contact our client service line immediately. If you are too far away and/or if the office is closed, please seek medical attention at a nearby urgent care clinic. Our office will reimburse you up to $100 for any related medical expenses subject to verification of your visit consult note and proof of payment.

        Vaccine Assistance Program

        In certain circumstances, uninsured patients who meet predefined income guidelines will be offered the option to receive required vaccines free of charge by participating in the Merk Vaccine Assistance Program. To apply, patients must provide demographic and income information which will be used strictly for administrative purposes and will not be shared with any governmental entities. If you choose not to participate in the program or are found to be ineligible for it, you will be responsible for the full cost of any vaccines you receive.

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