All questions or items must be answered fully and accurately 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out Part I, 'APPLICANT INFORMATION'. Ensure all fields are completed accurately, including the applicant's name, USCIS A-Number, and contact details. Use clear black ink if completing by hand.
3. Proceed to Part II, 'MEDICAL PROFESSIONAL INFORMATION'. The certifying medical professional should provide their details and check applicable licenses. If additional space is needed, attach continuation sheets as necessary.
4. In Part III, 'INFORMATION ABOUT DISABILITY and/or IMPAIRMENT(S)', the medical professional must answer all questions regarding the applicant's condition. This includes providing clinical diagnoses and explaining how the disability affects English comprehension.
5. Finally, ensure that both the medical professional and interpreter (if applicable) complete their certifications at the end of the form. Signatures must be dated appropriately.

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