The path to U.S. citizenship includes passing English and civics tests – requirements that seem straightforward until you consider applicants with dementia, severe cognitive impairments, or developmental disabilities.
For these individuals, Form N-648 provides a way to request exemption from testing requirements they genuinely cannot meet due to medical conditions.
But as of June 2025, USCIS has dramatically tightened its approach to disability waivers. The new policy emphasizes “integrity of the review process” and “identification and prevention of fraud,” signaling that officers will scrutinize these requests more aggressively than ever before.
Recent Policy Changes You Need to Know
USCIS Policy Alert PA-2025-10, effective June 13, 2025, represents a significant shift away from the more accommodative framework established in 2022.
The changes include:
- Mandatory concurrent filing – Form N-648 must now be submitted with your Form N-400, not separately afterward. Late submissions face heightened scrutiny.
- Increased fraud focus – The policy explicitly emphasizes detecting fraudulent medical certifications, with officers instructed to question validity more aggressively.
- Lower tolerance for errors – Missing information, vague descriptions, or incomplete sections now trigger automatic concerns about certification validity.
This tightened approach comes after USCIS identified multiple fraud schemes involving doctors who completed hundreds of N-648 forms for applicants they barely examined. The agency now tracks certifying professionals who submit high volumes of disability waivers.
How Form N-648 Works
Form N-648 allows applicants to request exemption from English and/or civics requirements when a physical or developmental disability or mental impairment prevents them from demonstrating required knowledge.
A licensed medical professional must complete the form, certifying under penalty of perjury that your condition prevents you from meeting these requirements.
This isn’t available just because the tests are difficult. The medical condition must be severe enough that you cannot learn or demonstrate English proficiency and civics knowledge, even with accommodations.
Qualifying Medical Conditions
USCIS applies strict standards for what qualifies. The condition must be:
- Medically determinable – Diagnosed through accepted clinical or laboratory techniques
- Long-lasting – Has lasted or is expected to last at least 12 months
- Sufficiently severe – Prevents learning or demonstrating English/civics knowledge
Conditions That Typically Qualify
- Dementia and Alzheimer’s disease
- Intellectual disability
- Autism spectrum disorder affecting communication and learning
- Severe cognitive impairments from stroke or traumatic brain injury
- Advanced Parkinson’s disease with cognitive decline
- Schizophrenia affecting cognitive function
- Severe learning disabilities preventing language acquisition
What Doesn’t Qualify
Several conditions – even serious ones – generally don’t meet the standard:
- Physical disabilities that don’t affect cognitive function
- Hearing or vision impairments alone (USCIS provides accommodations for these)
- Test anxiety or fear of failing
- Limited education or illiteracy without an underlying medical condition
- Being elderly (age alone isn’t a qualifying condition)
Who Can Complete Form N-648
Only three types of licensed professionals can certify the form:
- Medical doctors (M.D. or D.O.)
- Clinical psychologists
- Licensed clinical social workers (added in recent revisions)
The professional must be licensed to practice in the United States or its territories. More importantly, they must have actually treated you for the condition they’re certifying. USCIS heavily scrutinizes forms completed by doctors who only saw the applicant once, specifically to fill out N-648.
What the Form Must Include
Form N-648 requires detailed medical information that goes well beyond checking boxes.
Specific Diagnosis with Clinical Support
The medical professional must provide:
- Specific diagnosis using proper medical terminology
- Description of clinical findings and test results supporting the diagnosis
- Explanation of the impairment’s origin
- Duration of the condition and expected continuation
Vague descriptions like “memory problems” or “confusion” get rejected. USCIS wants specific diagnoses backed by clinical evidence.
Clear Connection to Testing Requirements
This section determines whether your request succeeds or fails. The medical professional must explain exactly how your condition prevents you from:
- Learning English (reading, writing, speaking)
- Learning U.S. history and government concepts
- Demonstrating this knowledge in a test setting
Generic statements that you “cannot pass the test” will be rejected. The doctor must connect specific symptoms of your diagnosed condition to inability to meet these specific requirements.
Clinical Evidence and Testing
Officers expect objective clinical findings from examinations and diagnostic tests:
- Mental status examination results
- Cognitive testing scores (like MMSE or MoCA)
- Brain imaging results if relevant
- Laboratory test results
- Functional assessments
Current Medications and Treatments
The form requires listing all medications and treatments for the condition. This helps USCIS verify the severity and ongoing nature of the impairment.
The Application Timeline
Under the new June 2025 policy, Form N-648 must be submitted with your Form N-400. While USCIS may accept late submissions “in limited circumstances,” these face increased scrutiny about why the disability wasn’t identified earlier.
Timing Your Medical Certification
Get your medical certification as close as possible to filing your N-400. Certifications older than six months may require updating.
What to Submit Together
Along with the completed N-648, include:
- Medical records supporting the diagnosis
- Test results referenced in the certification
- Treatment records showing ongoing care
- Any additional documentation that the medical professional mentions
The Interview Process
Even with an approved N-648, you still attend a naturalization interview. The process differs from standard interviews:
- The officer conducts the interview in your native language if you’re exempt from English requirements
- Questions focus on verifying your identity and application information
- The officer may ask about your medical condition to assess consistency with the certification
- You’re exempt from whichever requirements (English, civics, or both) the medical professional certified
- Officers can request additional medical evidence or examination if they doubt the certification’s validity
If Your N-648 Gets Rejected
USCIS will explain why your form was rejected.
Options include:
- Submitting a new N-648 with additional medical evidence addressing the stated deficiencies
- Requesting reconsideration with supplemental documentation
- Withdrawing the disability exception request and attempting the standard tests
- Working with an immigration attorney to address the reasons
Under the June 2025 policy changes, officers have a lower tolerance for resubmissions. Multiple N-648 submissions for the same applicant now trigger additional scrutiny.
Getting the Help You Need
Citizenship shouldn’t be impossible for applicants with legitimate medical conditions preventing them from passing the English and civics tests. Form N-648 provides a legitimate path forward, but success requires thorough medical documentation, a clear explanation of how your condition affects your abilities, and careful attention to USCIS’s heightened scrutiny.
The Law Office of Lina Baroudi in San Jose, California, works with applicants facing these challenges, helping coordinate between medical professionals and immigration requirements to build disability exception requests that meet USCIS’s strict standards.
If you have a medical condition that prevents you from learning or demonstrating English or civics knowledge, proper medical certification and experienced legal guidance can help you pursue naturalization despite these obstacles.
The information provided in this guest blog post is for general informational purposes only and does not constitute legal advice. Reading this post does not create an attorney-client relationship between you and The Law Office of Lina Baroudi, or any contributing author. Immigration law is complex and constantly evolving, and the application of law depends on the specific facts and circumstances of each individual case.