Documenting US Citizenship Examination Exemption for Medically Qualified Refugees

A 66-year-old patient, S.A., presents to my family medicine clinic with memory and concentration concerns. He is a refugee originally from the Democratic Republic of the Congo; his primary languange is Swahili. S.A. was tortured in the Democratic Republic of the Congo and then fled to Tanzania. He spent 17 years in a refugee camp in Tanzania and has now resided in the United States for 7 years. His history includes uncontrolled diabetes and no other medical conditions; however, on previous visits, he has mentioned having trouble sleeping.

S.A. tells me that he has attended English language classes regularly for 2 years but has made no improvement. He attributes this lack of progress to his inability to think and remember; he states that not being able to learn English is causing him a significant amount of stress. He recently heard from a friend about a form that doctors can complete for people who are unable to learn enough English to pass their citizenship examination. He asks whether I will complete this form for him. How can I determine whether this patient is a candidate for the medical exception for the US citizenship examination?

Refugee Naturalization

Since 1975, more than 3 million refugees have fled conflict, war, and persecution to be resettled in the United States.¹ Obtaining citizenship in a host country is an integral aspect of attaining stability for these individuals because it has been shown to decrease general psychological distress.^2,3 Citizenship also offers the right to vote in the United States and the ability to obtain a US passport.

Of particular significance to refugees who are disabled or older than 65 years, citizenship allows for continued receipt of Supplemental Security Income (SSI) benefits from the US Social Security Administration; these benefits otherwise terminate 7 years after a refugee's US arrival if they do not attain citizenship.⁴

One of the requirements for US citizenship through naturalization is a proficiency examination. Applicants must show competence in reading, writing, and speaking English, in addition to knowledge and understanding of US history, government, and civics.⁵ For patients with medical conditions that impair their ability to learn English and civics, this certifying examination can be a barrier to naturalization; however, a pathway to citizenship is possible for qualified applicants through completion of a Medical Disability Exception form.⁶

Medical Disability Exception Certification (Form N-648)

To qualify for a medical disability exception, a patient must have a medically determinable physical, developmental, or mental impairment or combination of impairments that has lasted or is expected to last at least 12 months and is not the result of illicit drug use. Medically determinable is defined as an impairment that results from abnormalities that can be diagnosed by medically acceptable clinical or laboratory diagnostic techniques.⁶

The current edition of form N-648 (updated August 19, 2022) can be found on the US Citizenship and Immigration Services website. The form must be completed by a licensed medical doctor, doctor of osteopathy, or clinical psychologist; it is submitted by the patient.⁷