Why Medical Documentation Matters in Attorney Files

Immigration attorneys who maintain comprehensive medical documentation in client files are better prepared to respond to RFEs, advise clients on case strategy, and track the status of medical findings that may affect adjudication.

The key is knowing what documentation to request, how to obtain it in compliance with HIPAA, and how to use it effectively in the representation.

Documentation to Request From the Civil Surgeon

With appropriate patient authorization, attorneys may request the following from the civil surgeon:

• A pre-seal copy of Form I-693 (before the envelope is sealed)
• Documentation of any abnormal findings and their classification (Class A or Class B)
• Vaccination records administered during the examination
• Laboratory test results (TB, syphilis, gonorrhea)
• Any referral letters for follow-up care or treatment

Documentation to Obtain From the Client

Attorneys should also obtain the following from the client:

• All available vaccination records, including childhood immunization records
• Medical records relevant to any chronic conditions or past medical history
• Records of any prior immigration medical examinations
• Documentation of any treatment for conditions identified during the examination
• HIPAA authorization forms allowing the attorney to communicate with the civil surgeon

HIPAA Authorization

Before requesting medical documentation from the civil surgeon, attorneys should obtain a signed HIPAA authorization from the client. This authorization allows the civil surgeon to share protected health information with the attorney.

The authorization should specify what information can be shared, with whom, and for what purpose. A general authorization for immigration purposes is typically sufficient.

Using Documentation for RFE Preparation

Medical documentation in the client file is invaluable for RFE preparation. If USCIS issues an RFE related to Form I-693, the attorney can quickly identify the relevant documentation, contact the civil surgeon for supplemental information, and prepare a comprehensive response. Attorneys who do not maintain medical documentation in client files are at a disadvantage when RFEs arise.