Application for Civil Surgeon Designation

Instructions for
Application for Civil Surgeon Designation
Department of Homeland Security
U.S. Citizenship and Immigration Services

USCIS
Form I-910
OMB No. 1615-0114
Expires XX/XX/201X

What Is the Purpose of This Form?
Form I-910 is to be used by physicians seeking designation as a civil surgeon.

What Is A Civil Surgeon?

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By law, a civil surgeon is a physician designated by the United States Citizenship and Immigration Services (USCIS) to
conduct immigration medical examinations for individuals seeking an immigration benefit in the United States.
Civil surgeon designation is required if you wish to conduct immigration medical examinations in the United States. If
you are not designated as a civil surgeon by USCIS, you are not authorized to conduct immigration medical examinations
in the United States or complete USCIS Form I-693, Report of Medical Examination and Vaccination Record.
Civil surgeon designation does not authorize a physician to conduct immigration medical examinations for individuals
seeking immigration benefits abroad through the visa issuance process of the United States Department of State (DOS).
Those immigration medical examinations are conducted by DOS-designated panel physicians overseas. For more
information, please visit the DOS Web site at www.travel.state.gov and search for "Panel Physicians".

Who Should Use Form I-910?

This form should be used by a physician who seeks to perform immigration medical examinations in the United States and
completes Form I-693, Report of Medical Examination and Vaccination Record, but who is not currently designated as a
civil surgeon.
NOTE: Physicians who qualify for blanket civil surgeon designation provided by USCIS are not required to apply for
civil surgeon designation on Form I-910. For information on blanket civil surgeon designations, please go to
www.uscis.gov/civilsurgeons.

What Professional Qualifications Are Required For Civil Surgeon Designation?
In order to be designated as a civil surgeon by USCIS, you must:

1. Be licensed without restriction as a Doctor of Medicine (M.D.) or Doctor of Osteopathy (D.O.) in the state in which
you seek to perform immigration medical examinations;
2. Have at least 4 years of professional experience as a physician; and
3. Be authorized to work in the United States.

Are There Other Requirements For Civil Surgeon Designation?
In addition to meeting the professional qualifications, you must:
1. Apply for civil surgeon designation using Form I-910;
2. Submit the completed Form I-910 with the correct fee; and
3. Currently have an active practice at the locations where you are requesting to perform immigration medical
examinations. USCIS will not grant your civil surgeon designation for locations where you only intend to practice in
the future.
Civil surgeon designation is at the discretion of USCIS. Although you may meet the professional qualifications and other
requirements as listed in Form I-910, there is no guarantee that you will be designated as a civil surgeon.

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What Are the Responsibilities Of A Civil Surgeon?
1. Report the results truthfully and accurately. Civil surgeons are responsible for truthfully and accurately reporting
the results of an applicant's immigration medical examination and all laboratory reports on Form I-693 where
indicated, and for signing the civil surgeon's certification provided on the form.
In this regard, the civil surgeon must take reasonable steps to ensure that the person appearing for the medical
examination is the same person applying for the requested immigration benefit. All applicants must present a valid
government-issued photo identification (example: valid unexpired passport or driver's license), and the civil surgeon
must annotate in Part 1. of Form I-693 the form of identification presented and ID number, if applicable. The law
imposes severe penalties for knowingly and willfully falsifying or concealing a material fact or using any false
documents in connection with this medical exam.

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The civil surgeon should also ensure that the applicant's name and A-number (if applicable) are at the top of each page
of the Form I-693 and that they match the information provided in Part 1. of Form I-693.
2. Follow HHS regulations and CDC guidelines. Civil surgeons are designated with the understanding that they will
perform the medical exam according to U.S. Department of Health and Human Services' regulations at 42 CFR part 34.
These regulations include the specific guidelines found in Technical Instructions for the Medical Examination of
Aliens in the United States (Technical Instructions), published by the Centers for Disease Control and Prevention
(CDC) in Atlanta, Georgia. The Technical Instructions (including periodic updates posted by CDC) are available on
the CDC Web site at http://www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/technical-instructions-civilsurgeons.html.
3. Make referrals and file case reports, as required. According to CDC's Technical Instructions, civil surgeons are
required to:
A. Refer the applicant to the local health department if the chest x-ray suggests tuberculosis (TB) or other healthrelated circumstances are present as described in CDC's Technical Instructions.
B. Ensure that any applicant diagnosed with syphilis is treated with the standard treatment regimen described in
CDC's Technical Instructions.
C. Ensure that testing and therapy are given for diagnoses of chancroid, gonorrhea, granuloma inguinale, or
lymphogranuloma venereum.
D. Refer the applicant to a Hansen's disease specialist for evaluation to confirm a suspected diagnosis of Hansen's
disease (leprosy).
E. File a case report with the appropriate public health authorities if a case report is required by local laws or
regulations. You must also advise the applicant that a case report is being filed.
4. Notify USCIS of any change(s) relevant to his or her designation as a civil surgeon. Civil surgeons are responsible
for notifying USCIS in the event that:
A. The civil surgeon ceases to practice medicine;
B. The civil surgeon ceases to perform immigration medical examinations in the state in which he or she is designated;
or
C. There is a change in the civil surgeon's contact information (e.g., name of office, address, telephone number, fax
number, or email address).
Civil surgeons must notify USCIS within 15 days of the change. See the section of these instructions entitled “When
and How Do I Update My Civil Surgeon Information?” for more information.

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Can Civil Surgeon Designation Be Revoked?
USCIS may revoke civil surgeon designation for cause, at any time. Reasons for revocation include, but are not limited to,
failure to continue to meet the professional qualifications required for civil surgeon designation, failure to meet the
responsibilities of a civil surgeon (including failure to follow CDC's Technical Instructions), engaging in immigration
fraud, or otherwise engaging in activity that poses a risk to public health or safety.

General Instructions
USCIS provides forms free of charge through the USCIS Web site. In order to view, print, or fill out our forms, you
should use the latest version of Adobe Reader, which can be downloaded for free at http://get.adobe.com/reader/.

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Each application must be properly signed and filed. A photocopy of a signed application or a typewritten name in place of
a signature is not acceptable.
Evidence. You must submit all required initial evidence along with all the supporting documentation with your application
at the time of filing.
Copies. Unless specifically required that an original document be filed with an application or petition, a legible
photocopy may be submitted. Original documents submitted when not required may remain a part of the record, and will
not be automatically returned to you.
Translations. Any document containing foreign language submitted to USCIS must be accompanied by a full English
language translation which the translator has certified as complete and accurate, and by the translator's certification that he
or she is competent to translate from the foreign language into English.
How To Fill Out Form I-910

1. Type or print legibly in black ink.

2. Answer all questions fully and accurately. If an item is not applicable or the answer is "none," leave the space blank.
3. If you need more space to provide additional information within this application, use the space provided in Part 10.,
Additional Information. Please provide the Page Number, Part Number, and Item Number to which your additional
information relates, to ensure the additional information you submit is considered as part of your application.
NOTE: While USCIS does not require you to do so, we suggest that you keep a copy of your application packet for your
own records.

Specific Instructions
Part 1. For Previously Designated Civil Surgeons
Complete this section only if you were previously designated as a civil surgeon.
Item Numbers 1.a. - 1.d. General Information about Previous Civil Surgeon Designation. If you were previously
designated as a civil surgeon, check “Yes” and provide the period of prior designation, the USCIS office that granted
the designation, and the Civil Surgeon Identification Number (CSID) issued, if known.
Item Numbers 2.a. - 2.b. Revocation. If your previous civil surgeon designation was revoked by USCIS, check “Yes”
and provide the date of revocation. Attach the revocation letter you received from USCIS, and also include a written
explanation of the circumstances surrounding the revocation in a separate letter attached to this application or in Part
10., Additional Information. Please note that USCIS may deny your application for civil surgeon designation if the
grounds upon which your previous designation was revoked still exist.
Item Numbers 3.a - 3.b. Voluntary Termination. If you voluntarily terminated your previous civil surgeon designation,
check “Yes” and provide the date of voluntary termination. You must also include a written explanation of the
circumstances surrounding the voluntary termination in a separate letter attached to this application or in Part 10.,
Additional Information.
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Part 2. Information About You
Item Numbers 1.a. - 1.d. Your Full Name. Write your last, first, and middle names in the appropriate fields.
Item Number 2. Date of Birth. Write your date of birth in month/day/year (mm/dd/yyyy) format.
Part 3. Clinical Office Location(s)
A. Required Information
Provide the name, physical address, telephone number, fax number, and e-mail address of the clinic or practice
where you intend to perform immigration medical examinations if granted civil surgeon designation. Failure to
provide this information may result in the denial of your application.

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If you seek to perform immigration medical examinations in more than one location, provide the details for each
additional location in Part 10., Additional Information.
NOTE: You must currently have an active practice at the locations where you are requesting to perform
immigration medical examinations. USCIS will not grant civil surgeon designation for locations where you only
intend to practice in the future.
NOTE REGARDING PHYSICAL ADDRESS: The physical address is the address where you are practicing
medicine and where applicants will come to have the medical examination performed. The physical address must
coincide with the location of your medical clinic or practice.
B. Optional Information for Civil Surgeon Locator

Additional information may be submitted to USCIS to be included in the public list of civil surgeons. USCIS will
update the public list with this information if and when feasible.
Part 4. Information About Your Status in the United States

In this section, provide information about the status you have been granted in the United States that would allow you to
practice medicine in the United States. Attach evidence to verify your legal status in the United States.
Item Numbers 1. - 4. Proof of Your Status in the United States. A physician meeting the professional qualifications
for civil surgeon designation can only be designated if authorized to work in the United States. Please specify whether
you are a U.S. citizen or national, a Legal Permanent Resident, or a nonimmigrant authorized to work as a physician in
the United States.
(1) If you select Item Number 3., you must also provide the information requested in Item Numbers 3.a. - 3.g.:
Item Number 3.a. The date of your last arrival to the United States;
Item Number 3.b. Your I-94 Arrival-Departure Record Number, if known;
NOTE REGARDING FORM I-94: If U.S. Customs and Border Protection (CBP) or USCIS issued Form
I-94, Arrival-Departure Record, to you, provide the I-94 admission number in the fields of this form where it is
requested. This number also is known as the Departure Number on some versions of Form I-94. If you do not
have an I-94 number, one of the following scenarios may apply:
1. If CBP or USCIS issued Form I-94 to you, but it is now lost or destroyed, you may apply for a
replacement by filing Form I-102, Application for Replacement/Initial Nonimmigrant Arrival-Departure
Document.
2. If CBP or USCIS did not issue Form I-94 to you and you believe that a Form I-94 should have been
issued, you may contact the agency you believe should have issued it to attempt to resolve the matter.
3. If CBP did not issue Form I-94 to you because it captured arrival information electronically, write
"N/A" in the fields that request an I-94 Arrival-Departure Record Number. In this instance, it is important
for the applicant to provide a passport or travel document number where it is requested on the form. (See
below.)
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Passport and Travel Document Numbers. CBP is exploring automation of Form I-94 Arrival-Departure
Record in order to collect arrival-departure information electronically, streamlining arrival and inspection for
travelers. If this occurs, CBP may scan a traveler's electronic passport (or, for travelers who do not have a
passport, some other similar "travel document") instead of issuing Form I-94. In these instances, applicants
must provide passport or travel document numbers - even if they have expired - instead of a Form I-94 number
when filing Form I-910.
Item Number 3.c. - 3.d. Your passport or travel document number;
Item Number 3.e. The name of the country that issued your passport or travel document;
Item Number 3.f. The date your passport or travel document expires; and

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Item Number 3.g. Your current nonimmigrant status.

(2) If you select Item Number 4., provide information in the space provided about any other status you have been
granted in the United States that would allow you to practice medicine in the United States.
Part 5. Medical License(s)

Civil surgeons must be licensed to practice medicine in the state(s) or territory(ies) in which they perform immigration
medical examinations. For each state or territory in which you seek to perform immigration medical examinations,
provide the name of the state or territory that issued your medical license, the medical license number, the date the
medical license was issued, and the date it expires. Attach a copy of your medical license(s) to your application.
Part 6. Medical Degree(s)

Only Doctors of Medicine (M.D.) and Doctors of Osteopathy (D.O.) may be designated as civil surgeons. Provide the
names of the school(s) you attended, your dates of attendance, and the type of medical degree(s) earned. Attach a copy
of your medical degree(s) to your application.
Part 7. Professional Experience

To be designated a civil surgeon, you must have at least 4 years of professional experience as a physician in the United
States. Provide your employers' names, the dates of employment, and employers' contact information to cover a period
of at least 4 years. NOTE: Time spent in a post-medical school training (including internships or residency programs)
cannot be counted toward this experience requirement. Attach evidence to verify your professional experience, such
as evaluations, certificates of completion, or letters of employment verification.
Part 8. Signature of Applicant

After reviewing the certification language, you must sign and date your application; USCIS will return your
application as incomplete if you fail to sign and date the form.
Part 9. Signature and Contact Information of Person Preparing This Application, If Other Than Applicant
Item Numbers 1a.- 4.b. If someone other than the applicant prepared this application, that individual must provide the
information requested.
Item Number 5. Please check the box if the preparer may act as a secondary point of contact for you, if USCIS is
unable to contact you using the information provided in Part 3., Clinical Office Location(s).
Item Number 6.a. - 6.b. After reviewing the declaration, the preparer must sign and date the application.
Part 10. Additional Information
In the space provided, you may add additional information regarding any item in the form, if needed. Please provide
the Page Number, Part Number, and Item Number to which the additional information relates, to ensure the additional
information you submit is considered as part of your application.

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You may also submit a statement with additional information in a separate letter, but you must annotate in Part 10.,
Additional Information, that you are attaching a separate letter. The letter must be submitted at the same time as this
Form I-910 application, and make reference to the Page Number, Part Number, and Item Number of Form I-910 to
which the additional information relates. Also include your full name and CSID number, if you have one, on each page
of the letter.

What Is the Filing Fee?
All applications must be accompanied by a fee of $615.

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If your application is accepted, USCIS will not refund the fee, regardless of the action taken on the application. Do not
mail cash. All fees must be submitted in the exact amounts.
Use the following guidelines when you prepare your check or money order for the Form I-910 fee:
1. The check or money order must be drawn on a bank or other financial institution located in the United States and must
be payable in U.S. currency; and
2. Make the check or money order payable to U.S. Department of Homeland Security.

NOTE: Spell out U.S. Department of Homeland Security; do not use the initials "USDHS" or "DHS."
Notice to Those Making Payment by Check. If you send us a check, it will be converted into an electronic funds
transfer (EFT). This means we will copy your check and use the account information on it to electronically debit your
account for the amount of the check. The debit from your account will usually take 24 hours and will be shown on your
regular account statement.
You will not receive your original check back. We will destroy your original check, but we will keep a copy of it on file.
If the EFT cannot be processed for technical reasons, you authorize us to process the copy in place of your original check.
If the EFT cannot be completed because of insufficient funds, we may try to make the transfer up to two times.
How to Check If the Fee Is Correct?

The filing fee on this form is current as of the edition date appearing in the lower left corner of this page. However,
because USCIS fees change periodically, you can verify if the fees are correct by following one of the steps below:
1. Visit the USCIS Web site at www.uscis.gov, select "FORMS," and check the appropriate fee; or

2. Call the USCIS National Customer Service Center at 1-800-375-5283 and ask for the fee information. For TDD
(hearing impaired) call: 1-800-767-1833.

Where To File
Please see our Web site at www.uscis.gov/I-910 or call the USCIS National Customer Service Center at 1-800-375-5283
for the most current information about where to file this application. For TDD (hearing impaired) call: 1-800-767-1833.

Where Is Civil Surgeon Information Listed?
USCIS provides a list of civil surgeons for public use. The list can be accessed in two ways:
1. Visit the USCIS Web site at www.uscis.gov/civilsurgeons and select “Find a Medical Doctor” from the right side of
the page; or
2. Call the USCIS National Customer Service Center at 1-800-375-5283 and follow the instructions in the automated
menu. For TDD (hearing impaired) call: 1-800-767-1833.

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When and How Do I Update My Civil Surgeon Information?
Civil surgeons must notify USCIS within 15 days of any change(s) relevant to their designation.
NOTE: If the change is an update to your contact information that involves practicing in a new state or territory, then you
MAY NOT perform immigration medical examinations in the new state or territory until USCIS approves the change. In
this case, you must submit the new contact information to USCIS with evidence that you are licensed to practice medicine
in the new state or territory in which you seek to perform immigration medical examinations.
Visit the USCIS Web site at www.uscis.gov/I-910 for the most current information about where to submit an update to
your civil surgeon information.

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USCIS will also conduct compliance reviews or audits to ensure the accuracy of the civil surgeon's information. As part
of these compliance reviews or audits, USCIS may contact civil surgeons on an ad hoc or ongoing annual basis to verify
some or all of the information provided on Form I-910. If USCIS is unable to verify a civil surgeon's continued eligibility
for designation or confirm contact information or determines that the civil surgeon is no longer practicing medicine or no
longer performing immigration medical examinations, USCIS may revoke or terminate the civil surgeon's designation and
remove him or her from the public list.

Frequently Asked Questions

Q. How long is the civil surgeon designation valid?

A. Currently, once a physician is designated a civil surgeon, the designation is valid until:
(1) USCIS is notified that the physician no longer practices medicine;

(2) USCIS is notified that the physician no longer intends to perform immigration medical examinations;
(3) The physician's work authorization in the United States expires, if the physician is only authorized to work in
the United States for a limited period of time; or
(4) Designation is revoked by USCIS.

Q. Where is my civil surgeon designation valid?

A. Once granted, civil surgeon designation is only valid in the location(s) that you indicated in your application. If you
wish to change or add locations associated with your civil surgeon designation, you must notify USCIS within 15 days
of such change. See the section entitled “When and How Do I Update My Civil Surgeon Information?” for more
information.
Q. I am a nonimmigrant or an alien authorized to work in the United States on a limited basis. Am I eligible for
civil surgeon designation?
A. Yes. However, your designation may only be valid to the extent that you have work authorization. For instance, if you
are authorized to work in the United States for one year, then your civil surgeon designation, if granted, would only be
valid during that year. If your immigration status is extended and you wish to remain designated as a civil surgeon,
you must re-apply for designation.
Q. Once I am a designated civil surgeon, am I required to perform immigration medical examinations?
A. No. You are authorized to perform immigration medical examinations, but not required. However, if you decide to stop
performing immigration medical examinations, you must notify USCIS and request removal from the civil surgeon list.
Once you are removed from the civil surgeon list, you will be considered to have voluntarily terminated your civil
surgeon designation and you must re-apply for civil surgeon designation on Form I-910 in order to be redesignated.
Q. Is there a required fee structure for the immigration medical examination?
A. No. USCIS does not mandate a fee structure for the immigration medical examination. However, civil surgeons should
be open and straightforward with applicants about fees associated with the immigration medical examination.

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Address Change
If you have changed your address, you must inform USCIS of your new address. For information on filing a change of
address go to the USCIS Web site at www.uscis.gov/addresschange or contact the USCIS National Customer Service
Center at 1-800-375-5283. For TDD (hearing impaired) call: 1-800-767-1833.
NOTE: Do not submit a change of address request to USCIS Lockbox facilities because USCIS Lockbox facilities do not
process change of address requests.

Processing Information

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Any Form I-910 that is not signed or accompanied by the correct fee, will be rejected with a notice that the Form
I-910 is deficient. You may correct the deficiency and resubmit the Form I-910. A Form I-910 is not considered properly
filed until accepted by USCIS.

USCIS Forms and Information

To ensure you are using the latest version of this form, visit the USCIS Web site at www.uscis.gov where you can obtain
the latest USCIS forms and immigration-related information. If you do not have internet access, you may order USCIS
forms by calling our toll-free number at 1-800-870-3676. You may also obtain forms and information by calling our
USCIS National Customer Service Center at 1-800-375-5283. For TDD (hearing impaired) call: 1-800-767-1833.
As an alternative to waiting in line for assistance at your local USCIS office, you can now schedule an appointment
through the USCIS Internet-based system, InfoPass. To access the system, visit the USCIS Web site. Use the InfoPass
appointment scheduler and follow the screen prompts to set up your appointment. InfoPass generates an electronic
appointment notice that appears on the screen.

Penalties

If you knowingly and willfully falsify or conceal a material fact or submit a false document with this Form I-910, USCIS
will deny the Form I-910 and may deny any other immigration benefit.
In addition, you will face severe penalties provided by law and may be subject to criminal prosecution.

USCIS Privacy Act Statement

AUTHORITIES: The information requested on this form, and the associated evidence, is collected under the
Immigration and Nationality Act, section 101, et seq.
PURPOSE: The primary purpose for providing the requested information on this form is to determine if you have
established eligibility for the benefit for which you are filing. The information you provide will be used to grant or deny
the benefit sought.
DISCLOSURE: The information you provide is voluntary. However, failure to provide the requested information, and
any requested evidence, may delay a final decision or result in denial of your form.
ROUTINE USES: The information you provide on this form may be shared with other Federal, State, local, and foreign
government agencies and authorized organizations following approved routine uses described in the associated published
system of records notices [DHS-USCIS-007 - Benefits Information System and DHS-USCIS-001 - Alien File, Index, and
National File Tracking System of Records, which can be found at www.dhs.gov/privacy]. The information may also be
made available, as appropriate, for law enforcement purposes or in the interest of national security.

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USCIS Compliance Review and Monitoring
By signing this form, you have stated under penalty of perjury (28 U.S.C. Section 1746) that all information and
documentation submitted with this form is true and correct. You have also authorized the release of any information from
your records that USCIS may need to determine eligibility for the benefit you are seeking and consented to USCIS'
verification of such information.
The Department of Homeland Security has the authority to verify any information you submit to establish eligibility for
the immigration benefit you are seeking at any time. USCIS' legal authority to verify this information is in 8 U.S.C.
Sections 1103 and 1222(b) and 8 CFR Part 232.2(b). To ensure compliance with applicable laws and authorities, USCIS
may verify information before or after your case has been decided. Agency verification methods may include, but are not
limited to: review of public records and information; contact via written correspondence, the Internet, facsimile, or other
electronic transmission, or telephone; unannounced physical site inspections of medical clinics or practices; and
interviews. Information obtained through verification will be used to assess your compliance with the laws and to
determine your eligibility for the benefit sought.

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Subject to the restrictions under 8 CFR Part 103.2(b) (16), you will be provided an opportunity to address any adverse or
derogatory information that may result from a USCIS compliance review, verification, or site visit after a formal decision
is made on your case or after the agency has initiated an adverse action which may result in revocation or termination of
an approval.

Paperwork Reduction Act

An agency may not conduct or sponsor an information collection, and a person is not required to respond to a collection of
information unless it displays a currently valid OMB control number. The public reporting burden for this collection of
information is estimated at 1 hour 51 minutes per response, including the time for reviewing instructions and completing
and submitting the form. Send comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden to: U.S. Citizenship and Immigration Services, Regulatory
Coordination Division, Office of Policy and Strategy, 20 Massachusetts Avenue NW, Washington, DC 20529-2140;
OMB No. 1615-0114. Do not mail your completed Form I-910 to this address.

Is Your Application Complete?

Please ensure that you have completed the following actions before you file Form I-910 with USCIS:
Did you fill out the form properly, leaving space(s) blank on any question(s) that did not apply to you?
Did you provide an original, handwritten signature and date your application? If you had someone else prepare
the application on your behalf, did that person sign and date the application? If that person was an attorney, did
the attorney submit Form G-28 with the application?
Did you include a check or money order according to the instructions in the section entitled "What is the Filing
Fee?"
Did you attach the required documentation or evidence including proof of your status in the United States, copies
of current state medical license(s) and medical degree(s), and proof of your professional experience?
If you intend to perform immigration medical examinations in more than one location, did you provide details
for each additional location in Part 10., Additional Information?

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