Immigration Medical Questionnaire

Complete this form at least 24 hours prior to your appointment

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        Personal Information

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

        Immigration Information

        This is a nine digit number that USCIS assigns to your 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

        You require an interpreter for your medical exam today. Please list your interpreter's information below:

        COVID-19 Vaccination Requirement

        All applicants ages 5+ must complete the primary COVID-19 vaccine series before the Civil Surgeon can sign off on their medical report. The primary COVID-19 vaccine series consists of either one dose of the Janssen COVID-19 vaccine or two doses of Moderna, Pfizer or another approved COVID-19 vaccine.

        If an applicant refuses to complete the COVID-19 vaccine series, the Civil Surgeon in most cases must mark a box indicating that the applicant does not meet immunization requirements. This mark would result in the applicant being considered medically inadmissible to the United States and his/her adjustment of status application would mostly likely be denied by USCIS.

        Notwithstanding, individuals who refuse all vaccinations on moral and/or religious grounds may file a waiver of inadmissibility at a cost of $930 using USCIS Form I-601. If you intend to file this waiver, please notify a member of the office staff prior to your appointment. Note that the USCIS officer reviewing your case will use their discretionary authority in deciding whether or not to approve a waiver of inadmissibility.

        FIRST DOSE OF COVID-19 VACCINE:

        DOSE OF COVID-19 JANSSEN VACCINE:

        SECOND DOSE OF COVID-19 VACCINE:

        Medical/Social Information

        Vaccination Consent

        IMPORTANT: Prior to your appointment, please use the website link provided below to learn about the potential contraindications and common adverse reactions associated with any vaccines which you will receive here at Gateway Medical: https://www.cdc.gov/vaccines/hcp/vis/current-vis.html

        Optional Services

        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 already submitted their underlying adjustment of status application (Form I-485) prior to completing the immigration medical examination must submit their medical report (Form I-693) to USCIS within 60 days of the civil surgeon signing it, Clients who have exceeded their 60 day filing deadline may request an "update" to their Form I-693 at a cost of $25 provided that not more than 180 days has passed since the date of the civil surgeon's original signature. After that period of time has elapsed, you may be required to undergo and pay for repeat laboratory testing and/or a new physical examination.

        Adverse Reactions

        If you feel that you are experiencing a serious allergic reaction to a vaccination which was administered in the office, we ask that you contact us immediately at 800-339-9556 . If you are too far away to visit us in-person and/or if the doctor is not available, please seek medical attention at a nearby urgent care clinic.

        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 MERCK 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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