Form DS-5541 Immigrant Healthcare Questionnaire

U.S. Department of State

IMMIGRANT HEALTHCARE QUESTIONNAIRE

OMB APPROVAL NO.1405-XXXX
EXPIRATION Date: XX/XX/20XX
ESTIMATED BURDEN: 10 MINUTES

PART 1 - INFORMATION ABOUT YOU
1. Your Current Legal Name (Do not provide a nickname)
Family Name (Last Name) Given Name (First Name) Middle Name

PART 2 - YOUR HEALTH
2. Will you be covered by health insurance in the United States within 30 days of your entry into the United States?
Yes

No

3. If you answered "yes" to Question 2, identify the specific health insurance plan and date coverage will begin.

4. If you answered "no" to Question 2, how do you plan to pay for healthcare for your existing medical conditions in the United States?

Federal Agency Disclosure and Authorizations
PAPERWORK REDUCTION ACT STATEMENT
Public reporting burden for this collection of information is estimated to average 10 minutes per response, including time required for searching existing
data sources, gathering the necessary documentation, providing the information and/or documents required, and reviewing the final collection. You do
not have to supply this information unless this collection displays a currently valid OMB control number. If you have comments on the accuracy of this
burden estimate and/or recommendations for reducing it, please send them to: PRA_BurdenComments@state.gov.
CONFIDENTIALITY STATEMENT
INA Section 222(f) provides that visa issuance and refusal records shall be considered confidential and shall be used only for the formulation,
amendment, administration, or enforcement of the immigration, nationality, and other laws of the United States. Visa records may be disclosed in
certain situations, as described in INA Section 222(f), including disclosure to a court as needed in a case pending before the court.
DS-5541
10-2019

UNCLASSIFIED