Protection & Advocacy, Inc.

LOS ANGELES LEGAL OFFICE, 3580 Wilshire Boulevard, Suite 902, Los Angeles, CA 90010-2512, Telephone: (213) 427-8747, Fax: (213) 427-8767, Toll Free/TTY/TDD: (800) 776-5746, legalmail@pai-ca.org

Instructions to Doctors Re: Completing the N-648 Medical Certification for INS Disability Waivers for Applicants Seeking Naturalization

Dear Doctor,

Thank you for your time and cooperation in helping your patient with a naturalization application. Your patient has asked for your help in getting a disability waiver. Generally, applicants for citizenship must be able to read, write and speak English, and have knowledge of U.S. history and civics. However, an applicant who qualifies for a "disability waiver" is exempt from one or both of these requirements.

Who is Eligible for a Disability Waiver

1. An applicant for a disability waiver must have a medically determinable physical or developmental disability, or mental impairment, that causes the applicant to be unable to learn English and/or U.S. history and civics.

2. The disability must be expected to last at least 12 months.

3. The disability must not be the result of illegal drug use.

The Doctor's Role in the Application Process

When deciding whether the disability waiver should be granted, the Immigration and Naturalization Service (INS) relies on the medical opinion of the applicant's doctor, who must be a medical doctor or clinical psychologist licensed in the U.S. The doctor provides this medical opinion completing INS Form N-648 (Medical Certifications for Disability Exceptions). Attached are specific instructions for completing each section of the N-648.

Diagnosing Mental Impairments

Some patients may have mental impairments, such as depression or dementia, which are not the presenting diagnosis, but may nonetheless make it impossible to learn English. Attached is a "Cognitive Disability Battery" with an interview checklist and simple testing protocol you can be use to support a diagnosis of a mental impairment. This testing battery is for your use as a doctor; you should keep it in your patient's chart to support your diagnosis. Do not send it to INS. Since INS requires a DSM IV code number, references for common diagnoses are listed at page 5.

1. Print or type your answers on the form or attach a separate answer sheet. INS officials say they cannot read handwriting and will reject medical certifications if they are not legible. If you attach a separate document, you must still sign the certification form and write in the space after each question: "See attached letter."
2. You do not have to, and should not, seal the envelope containing the completed medical certification. The applicant has a right to review the completed medical certification form. Sealing the envelope was required for Civil Surgeon opinions regarding visa adjustment. It is not required for naturalization applications.
3. Illegal use of drugs - Question 4. If, in response to Question 4, you believe that the disability may be the result of the illegal use of drugs (or you are not sure whether drugs are involved), DO NOT COMPLETE THE FORM. If any information regarding illegal drug use is disclosed to INS, your patient may face deportation.
4. Meaningful oath requirement. The INS is requiring that all applicants for naturalization have the ability to take a meaningful oath of allegiance to the U.S. If you believe that the applicant can understand the oath, even though she cannot learn English, mention this on Form N-648. If you are uncertain, do not mention the applicant's competence or ability to take the oath, as this is not required on Form N-648.
5. Your qualifications - Question 6. You do not have to be a specialist, as long as you are familiar with the causes and symptoms associated with your patient's disability. This experience may come from treating other patients or from medical training.
6. Truthfulness of certification. The doctor signs Form N-648 under penalty of perjury. This certification under penalty of perjury is no different from the truthfulness standard required for signing other government forms and insurance claim statements. Note that as long as you do not knowingly provide false information to the INS, you cannot be subjected to any civil penalties or liabilities.

If the INS officer needs more information, she may contact the certifying doctor for supporting documentation. Since INS examiners have no medical experience, they may ask you to explain the basis for your diagnosis. If INS questions you, please explain that clinical evidence may include statements from the patient and her family about the her mental state. (See, for example, the attached interview checklist and applicant questionnaire.) Note: In Part 1 of Form N-648, the applicant has agreed to release her medical records for purposes of the naturalization application.

1. Describe your patient's symptoms - Question 3. This is the most important part of the form. Your answer must have these three parts (the three "C"s):

(A) The nature and origin of your patient's disability or illness (CAUSE);

(B) The specific symptoms associated with the disability or illness which make it impossible for him to learn English and/or U.S. history and civics (CONNECTION); and

(C) Your conclusion that the applicant cannot learn English and/or cannot learn U.S. history and civics (CONSEQUENCE).

1. In answering Question 3, the following symptoms are relevant to the CONNECTIONbetween the disability and learning English and/or U.S. history and civics:

Memory impairment: inability to learn new information or to recall previously learned information;

Disturbance in executive functioning, which involves planning, organizing, sequencing and abstracting;

Difficulties with concentration and focus;

Delirium, disorientation, confusion, agitation;

Difficulty in expressing herself or in understanding what is said to her (expressive/receptive communication disorders);

Painful or medically fragile conditions that impair concentration and prevent your patient from leaving home to attend English and/or U.S. history and civics classes;

Fatigue, loss of energy or a sense of hopelessness (often associated with depression), which impairs concentration and prevents your patient from leaving home to attend English and/or U.S. history and civics classes;

Paranoia, hostility, anxiety and/or delusions which prevent your patient from expressing what she knows or has learned;

Unpredictable behavior in response to stress and anxiety (which may be a result of post-traumatic stress disorder or other anxiety disorders) so that your patient cannot perform in a testing, classroom or interview/interrogation setting;

Low intellectual functioning and/or learning disabilities that affect reading and writing ability.

1. In answer to Question 4 on the medical certification, developmental disabilities must be manifested before age 22. If you did not treat the patient prior to age 22, explain how you know that this requirement is met, for example, you can explain that (a) this is a condition (such as cerebral palsy) which only occurs at birth, (b) you have reviewed medical records from when your patient was under age 22, or (c) family members reported the existence of clinical symptoms indicating developmental delays prior to age 22 -- such as learning difficulties, placement in special education, or eligibility for regional center services.
2. For regional center doctors, it is preferable to schedule an appointment to examine the applicant before completing Form N-648. If this is impossible, in response to Question 1, which asks the date of the last examination, indicate the date you reviewed the regional center medical records. On a separate sheet, explain that the nature and severity of the of the developmental disability is so clear and well-documented that a physical examination is unnecessary.

1. Because physical illness or disability alone will not prevent your patient from learning English and/or U.S. history and civics, you must identify those symptoms associated with the condition which do affect his ability to pass the tests. For example, illness may be accompanied by pain, fatigue or nausea, which prevent him from attending classes and studying, and which impair concentration.
2. Medication or treatment for a condition may affect vision, cause drowsiness or nausea, or have other side effects that prevent your patient from the physical act of attending classes and studying.
3. Patients who are deaf may be able to learn English and U.S. history and civics through written materials. The answer to Question 3 must explain why this is not possible for your patient. For example, if he is illiterate in his own language, or if there are no learning materials available in his language, then he cannot learn English and U.S. history and civics if he is deaf. Similarly, you must explain why a patient who is blind cannot learn English through audiotapes -- if, for example, there are no audiotapes available in his primary language, then he cannot learn English and U.S. history and civics if he is blind.
4. Illness and physical disability may also be accompanied by mental impairments as discussed below.

1. If your patient already has a diagnosis of a psychiatric disability, such as schizophrenia or bi-polar illness, your medical certification needs to list his symptoms. Many of those symptoms will already be documented in his medical records.
2. If you are a general practitioner, the mental disorder may be secondary and may not be the reason your patient initially came to you for treatment. You do not have to refer your patient to a psychiatrist or clinical psychologist to complete Form N-648 regarding a mental impairment. (As we discuss below, you may want to refer your patient for follow-up treatment, but a referral only for the INS medical certification is unnecessary and expensive.)

INS requires that the mental disorder be "medically determinable." "Medically determinable" is defined as resulting from anatomical, physiological, or psychological abnormalities which can be shown by medically acceptable clinical and laboratory diagnostic techniques. Clinical techniques include interviewing the patient and/or her family to identify symptoms. The attached "Cognitive Disability Battery" will provide clinical evidence of a mental impairment for purposes of the INS medical certification. However, since INS does not want copies of any medical records or test results, keep the completed testing battery in your patient's chart; do not send it to INS as an attachment to the medical certification.

1. Follow-up on a diagnosis of a mental disorder. If you are not a mental health professional, and you identify a mental disorder that could be alleviated through treatment, you may refer your patient for follow-up treatment. Resources include the county mental health clinics and some nonprofit community centers.
2. Examples of DSM IV diagnostic codes. These codes might be relevant for elderly immigrant patients not previously diagnosed with a mental disorder:

293.0 Delirium due to (general medical condition)

780.09 Delirium, Not Elsewhere Specified (NOS)

290.10 Dementia of Alzheimer Type, uncomplicated

290.40 Vascular Dementia, uncomplicated

294.1 Dementia due to (general medical condition, can include MS, etc.)

295.8 Dementia NOS

294.0 Amnestic Disorder due to (general medical condition)

205.8 Amnestic Disorder NOS

296.30 Major depressive disorder, recurrent, unspecified severity

300.4 Dysthymic disorder

309.81 Post-traumatic stress disorder

300.02 Generalized anxiety disorder

300.00 Anxiety disorder NOS

309.0 Adjustment reaction with depressed mood

CAUSE: Mrs. A. has congestive heart failure, atherosclerosis and high blood pressure. These conditions were diagnosed approximately three years ago.

CONNECTION: As a result of these conditions, Mrs. A. has symptoms of extreme fatigue, recurrent pneumonia and debilitating headaches. As a result of her fatigue, frequent illness and headaches, she cannot attend English language or U.S. history and civics classes, and does not have the stamina to study on her own. Moreover, her fatigue and headaches make it impossible for her to concentrate enough to learn a new language or to memorize new information.

CONSEQUENCE: Mrs. A. is unable to pass the written or spoken English tests or the U.S. history and civics test in order to naturalize.

CAUSE: Mr. B. has vascular dementia secondary to arterial hypertension and heart disease, DSM IV 290.40. He was diagnosed in this office four years ago.

CONNECTION: Symptoms of his dementia include memory impairment (an impaired ability to learn new information or recall previously learned information), and cognitive disturbances, including an impairment of executive functioning, planning, sequencing, organizing and abstracting information. As a result of these symptoms, Mr. B. does not have the ability to learn a new language or to recall what he may have learned in the past. CONSEQUENCE: Mr. B. is unable to pass the written or spoken English tests or the U.S. history and civics test in order to naturalize.

CAUSE: Ms. C. is blind and also has severe, recurrent depressive episodes with psychotic features, DSM IV 296.34.

CONNECTION: Ms. C.'s symptoms include fatigue, inability to concentrate and a sense of hopelessness. She also has delusions that her children are stealing from her. Her depression and delusions result in functional disability so that she is unable to leave her home due to fatigue and fear. As a result, she cannot attend classes to learn English or U.S. history and civics. She cannot initiate new tasks, such as studying from audio tapes. Her psychological symptoms also make it impossible for her to overcome the disability posed by her blindness.

CONSEQUENCE: As a result of the combination of her blindness and depression, Mrs. C. is unable to pass the written or spoken English tests or the U.S. history and civics test in order to naturalize.

If you have more questions about completing the medical certification Form N-648, you or your patient can call PAI at 1-800-776-5746 and ask for an intake appointment.

Applicant's Name: _______________________________ Age: _______ Sex: _______

Physician's name: _________________________________ Today's date: ___________

Name of translator: ___________________________ Relationship to applicant: ________

Instructions:

1. Please review the Applicant Questionnaire completed by your patient and clarify any problem areas.

2. Complete the checklist below based on your observations and the material gathered in the Applicant Questionnaire.

3. Administer the Cognitive Test on the following pages.

4. Classify the degree of cognitive impairment indicated at the bottom of this page.

Checklist

Check which cognitive symptoms you have observed in the patient/applicant or you believe the patient has based on their questionnaire:

___ disorientation to time, place, person

___ confusion

___ inability to carry out actions

___ expressive or receptive language problems (other than English deficiencies)

___ dressed inappropriately for weather

___ unable to identify spouse

___ unable to identify you

___ unable to identify who brought him/her to evaluation

___ slowed response times

___ severe concentration problems

___ significant short term memory loss

___ unable to recall major life events

___ poor hygiene

___ gait disturbance

___ unable to write legibly

___ serious depression

___ flat affect

___ agitation

___ delusional thinking

Scoring:

Total the number of failed items on the Cognitive Deficit Test. This is the Deficit Score. For each observation checked above, add 1 point to the Deficit Score.

Deficit Score -- Degree of Cognitive Impairment

0-9 -- little or none

9-16 -- mild to moderate

>16 -- moderate to severe

Those with moderate to severe impairment probably cannot learn English or civics information adequately.

Applicant's Name: ________________________________ Age: _______ Sex: ______

Date of birth: ___________ City and Country where born: ________________________

Education: _______________ What languages do you speak: ______________________

Address: ______________________________________________________________

Phone number: ______________________

Instructions: Please read these questions to the applicant in their native language and fill in the answers. If necessary, explain the question. If you know the answer to a question but the applicant does not or if it is something you have observed, put your initials next to the answer.

Today's date: ___________

Name of person translating: _______________ Relationship to applicant: __________

History

What kinds of jobs have you had? ___________________________________________

What is the worst sickness you have ever had? __________________________________

How many times have you been in the hospital? __________

Check which of the following have you ever had:

___ knocked unconscious

___ heart attack

___ stroke

___ diabetes

___ cancer

___ high blood pressure

___ treated by a psychiatrist (a mental doctor)

___ seizures or fainting

Current condition:

Current medical problems:

_____________________________________________________________________

Current medicines:

_____________________________________________________________________

How much alcohol do you drink each week? __________

How much do you smoke each week? __________

Does someone else keep your money, pay your bills and do all your shopping? Yes No

Can you read signs in English? Yes No

Can you read an English newspaper or book? Yes No

Current Symptoms: Check the problems you have now:

Thinking and learning:

___ can't learn English even when you tried

___ very slow to understand things

___ lose track of what you are thinking

___ mind goes blank

___ difficulty solving problems

___ difficulty making change at the store

___ difficulty following recipes

___ can't tell right from left

___ can't do simple arithmetic

___ trouble learning new things

___ often disorganized

___ get very confused

Orientation:

___ forgetting your name

___ forgetting where you are

___ forgetting what the date is

___ forgetting your address and phone number

___ forgetting when and where you were born

___ get lost easily

___ difficulty recognizing people you know

Language:

___ unable to say words

___ unable to read things in your native language

___ slurred speech

___ difficulty writing

___ forgetting the names of common objects

___ trouble giving and understanding directions to places

___ unable to write or spell your own name

Motor:

___ difficulty getting dressed

___ tremors or shakiness

___ problems drawing

___ can't control muscles

___ can't use utensils to eat

Memory:

___ cannot remember things that happened recently

___ can't pay attention for more than a minute

___ very easily distracted

___ forgetting to do things

___ forgetting the names of your family members

___ losing things around the house

Psychological:

___ chronic sadness

___ a lot of anxiety and worry

___ seeing or hearing things others do not

___ extreme fatigue

___ feeling hopeless most of the time

___ impatience with yourself and others

___ loss of interest in most everything

Daily living skills:

___ can't use the phone

___ forgetting the value of coins

___ can't use basic tools (like scissors)

___ can't use public transportation

___ can't cross the street safely

___ not concerned about hygiene

___ can't help around the house

___ can't order food in a restaurant

___ can't tell time

___ needs help using the toilet