An RFE medical exam refers to what happens when U.S. Citizenship and Immigration Services (USCIS) sends you a Request for Evidence asking you to submit, correct, or update the immigration medical examination tied to your green card application. The medical exam itself is documented on Form I-693, Report of Medical Examination and Vaccination Record, and it is a required step for nearly everyone applying for lawful permanent residence through adjustment of status. Getting an RFE about it does not mean your case is being denied. It means USCIS needs something specific before it can move forward, and you have a limited window to provide it.
Why USCIS Issues an RFE for the Medical Exam
USCIS can issue an RFE related to the medical exam for several reasons, and understanding which one applies to you determines how you respond. The most common scenarios include:
- Missing I-693: You did not submit the medical exam form with your initial adjustment of status application, or it was separated from your file during processing.
- Expired exam: The I-693 has a validity period, and if your case took longer than expected to adjudicate, the exam you submitted may have expired before an officer reviewed it.
- Incomplete vaccinations: The civil surgeon marked one or more required vaccinations as missing, and you did not provide evidence of a waiver or a plan to complete the series.
- Errors on the form: The civil surgeon made a mistake, left a field blank, used an outdated edition of the form, or failed to sign or date it properly.
- Unclear medical findings: The officer reviewing your file needs clarification on a condition noted by the civil surgeon, particularly if it could affect admissibility.
The RFE letter will specify what USCIS needs and give you a deadline, typically 84 days (about 12 weeks), though this can vary. Missing the deadline without responding can result in your application being denied based on the evidence already in the file.
What the Immigration Medical Exam Covers
The Form I-693 medical exam is not a general health checkup. It is a structured evaluation performed by a USCIS-designated civil surgeon, a licensed physician who has been approved to conduct immigration medical examinations. You cannot use your regular doctor unless that doctor happens to hold a civil surgeon designation.
The exam includes a physical examination, a review of your medical history, specific lab tests, and a vaccination assessment. The physical exam covers vision, hearing, and a general check for signs of communicable diseases or physical or mental conditions that could be relevant to admissibility. The civil surgeon will also ask about your history of drug or alcohol use and any mental health conditions. These questions are not casual conversation; they feed into determinations about whether any “Class A” or “Class B” conditions exist.
Lab work typically includes a tuberculosis screening, which starts with an interferon-gamma release assay blood test or, in some cases, a tuberculin skin test. If the screening comes back positive, a chest X-ray is required to check for active disease. Syphilis testing through a blood draw is standard. For immigrant visa applicants, screening also covers gonorrhea, with optional testing for chlamydia depending on local lab capabilities.1Journal of Travel Medicine. Outcomes of systemic screening for syphilis, gonorrhoea and Chlamydia trachomatis among immigrant visa applicants migrating from Japan to the US in 2016–2019
Vaccination Requirements and What Happens When You Are Behind
Vaccination compliance is one of the most common reasons an RFE gets issued. USCIS requires applicants to show proof of vaccination against a specific list of diseases. The list is set by the Advisory Committee on Immunization Practices and currently includes measles, mumps, rubella, polio, tetanus and diphtheria, pertussis, hepatitis A, hepatitis B, rotavirus, meningococcal disease, varicella, pneumococcal disease, seasonal influenza (when in season), and COVID-19, among others. The list can change, and the specific vaccines required depend on your age.
If you grew up outside the United States, there is a decent chance your childhood vaccination records do not match up perfectly with the U.S. schedule. Some countries use different vaccine combinations or different dosing intervals. The civil surgeon reviews whatever records you bring and determines what is missing. If you need additional shots, you can get some at the exam appointment itself and schedule others for later. For multi-dose vaccines like hepatitis B, the civil surgeon may note that the series is “in progress” and mark which doses you have received.
The problem arises when USCIS reviews the I-693 and sees incomplete vaccination series with no indication of when you plan to finish them. An RFE in this situation asks you to provide either updated vaccination records showing completion or documentation from a civil surgeon explaining the schedule for remaining doses. If you have a medical or religious reason for not receiving certain vaccines, a waiver request can be submitted, but it needs to be documented properly on the form.
Class A and Class B Conditions
Immigration law divides health-related findings into two categories that affect your case differently. Class A conditions are grounds for inadmissibility, meaning they can block your green card outright unless you obtain a waiver. Class B conditions are noted on the form but do not, on their own, prevent you from getting approved.
Class A conditions include active tuberculosis, certain sexually transmitted infections that are considered communicable diseases of public health significance, a physical or mental disorder with associated harmful behavior, and drug abuse or addiction. For sexually transmitted infections, syphilis and gonorrhea are specifically screened for, and positive results for these can affect admissibility.2Ovid. Sexually Transmitted Infection Screening for Immigrant Entry Into the United States: A Narrative Review of Current Practices and Recommendations for Improvement In practice, most of these conditions are treatable, and an applicant who completes treatment can have the Class A designation removed before the exam is finalized or resubmitted in response to an RFE.
Class B conditions include things like treated (inactive) tuberculosis, a physical or mental condition that does not pose a current threat, or a history of substance use that does not meet the threshold for a Class A finding. These get documented but do not trigger inadmissibility. However, they may prompt USCIS to request more information through an RFE, especially if the civil surgeon’s notes are vague or if the condition could arguably be reclassified.
If your RFE mentions a Class A condition, the path forward usually involves getting treated, obtaining documentation of successful treatment from the civil surgeon, and submitting an updated I-693 or a supplemental letter. For certain Class A conditions, you may also need to apply for a separate inadmissibility waiver, which is a different form and process.
Mental Health and Substance Use Questions
The mental health portion of the exam catches some applicants off guard. The civil surgeon is required to assess whether you have a physical or mental disorder that is associated with harmful behavior toward yourself or others. This is not a psychiatric evaluation in the clinical sense, but it involves direct questions about your mental health history, any history of violent behavior, and your use of drugs and alcohol.
Having a mental health condition does not automatically create a problem. Depression, anxiety, PTSD, and other common conditions are not Class A findings unless they are accompanied by behavior that has caused harm. The civil surgeon is looking for a specific combination: a diagnosed disorder plus associated harmful behavior that has occurred in the past or is reasonably expected to occur. If that combination is not present, the condition may be noted as Class B or not flagged at all.
Drug use is a more sensitive area. Admitting to past use of controlled substances, even marijuana in states where it is legal, can trigger a Class A finding because federal immigration law still treats any illicit drug use as relevant. Civil surgeons are required to ask about it. If an RFE touches on substance use findings, consulting with an immigration attorney before responding is strongly advisable, because the way information is presented can significantly affect the outcome.
How to Respond to the RFE
The response to an RFE for a medical exam depends entirely on what USCIS is asking for. In most cases, it involves one or more of the following steps: scheduling a new appointment with a civil surgeon, getting a corrected or updated I-693, completing outstanding vaccinations, or providing supplemental documentation about a medical finding.
If the original I-693 simply expired, you will need a brand-new exam. This means going back to a civil surgeon, going through the full process again, and submitting the new form. If the issue is a minor error, some civil surgeons will correct and re-sign the existing form, but others prefer to redo the exam entirely, especially if significant time has passed. Either way, the corrected or new I-693 needs to be sent to USCIS before the RFE deadline, along with any other documents the RFE letter requests.
When mailing your response, send it to the address specified in the RFE letter, not the general USCIS filing address. Include a copy of the RFE notice itself so the mailroom can match it to your case. Use a trackable delivery method. USCIS has been known to claim non-receipt of timely responses, and having a delivery confirmation protects you.
I-693 Validity and Timing Strategy
The I-693 is valid for two years from the date the civil surgeon signs it, but there is a catch: USCIS must accept the form while it is still valid. If your adjustment of status case is stuck in a long processing queue and the two-year window passes before an officer picks up your file, you will get an RFE asking for a new exam. This is one of the most frustrating RFE scenarios because it costs you money and time for something entirely outside your control.
Timing the medical exam is a balancing act. If you submit the I-693 too early, it might expire before adjudication. If you wait too long, you might miss the window where USCIS would have approved your case without needing it. Many immigration attorneys recommend not submitting the I-693 with the initial application if you expect long processing times. Instead, they suggest waiting until USCIS either schedules an interview or issues an RFE, then getting the exam done quickly so the two-year clock starts as late as possible.
That said, USCIS has been adjudicating some categories of adjustment cases without interviews in recent years, and in those situations, having the I-693 already in the file can prevent a delay. There is no universally right answer here, and the best strategy depends on your specific case type, your USCIS field office, and current processing trends.
Cost and Logistics
USCIS does not set a fixed fee for the medical exam; each civil surgeon sets their own price. Costs typically range from around $200 to over $500, depending on your location and what is included. Some civil surgeons bundle the lab work and vaccinations into their fee, while others charge separately. If you need several vaccines, the total can climb quickly. The exam is not covered by most health insurance plans because it is classified as an immigration-related service rather than a medical necessity.
Finding a civil surgeon is done through the USCIS website, which maintains a searchable directory. Not every physician listed is still actively practicing as a civil surgeon, so call ahead and confirm before scheduling. Bring your passport, vaccination records (if you have them), any prior medical records relevant to conditions the civil surgeon might ask about, and the confirmation page from your pending adjustment of status case. The appointment itself typically takes one to two hours, though you may need to return for lab results or follow-up vaccinations.
If you are responding to an RFE, factor in turnaround time. Lab results can take a few days to a week, and if you need a chest X-ray for tuberculosis, that adds another step. Build in at least three to four weeks of buffer before the RFE deadline to account for scheduling delays and lab processing.
How Medical Exams Create Uncertainty in the Process
On paper, the immigration medical exam looks straightforward: get checked by a doctor, prove you are vaccinated, and move on. In practice, the process introduces its own set of complications that can disproportionately affect certain applicants. Research examining the role of medical examinations in immigration adjudication has found that these biological screening mechanisms, while appearing objective and standardized, can create added uncertainty and obstacles that unevenly impact different groups of people.3Oxford Academic (Social Problems). Biopolitical Citizenship in the Immigration Adjudication Process
Some of that unevenness comes from cost. An applicant who needs to redo an expired exam and catch up on several vaccinations might pay over a thousand dollars out of pocket, on top of the filing fees they have already paid for the adjustment of status application itself. For families with multiple applicants, the expenses multiply. There is no fee waiver available for the medical exam, even though fee waivers exist for the underlying USCIS application.
Other complications are structural. Applicants from countries with different vaccination schedules may face more difficulty proving compliance. Those with past mental health treatment or substance use histories face more scrutiny during the exam. And applicants in rural areas may have fewer civil surgeons to choose from, leading to longer wait times and travel costs that urban applicants do not face. None of these factors are formally counted against you in the adjudication, but they add friction, expense, and delay that accumulate unevenly.
The Domestic Medical Exam After Arrival
The RFE medical exam discussed above applies to people adjusting status inside the United States. A separate but related process exists for refugees, asylees, special immigrant visa holders, and Cuban/Haitian entrants. These populations are eligible for a domestic medical examination conducted shortly after they arrive in the country, which serves a different purpose: identifying health conditions that need follow-up treatment and connecting newly arrived individuals to the U.S. healthcare system.4PLoS Medicine. Health screenings administered during the domestic medical examination of refugees and other eligible immigrants in nine US states, 2014–2016: A cross-sectional analysis
This domestic exam is not the same as the Form I-693 exam and does not replace it for adjustment of status purposes. Refugees, for instance, undergo an overseas medical exam before arriving in the U.S. and then receive the domestic screening afterward. If a refugee later applies for adjustment of status to become a permanent resident, they may still need a new I-693, depending on how much time has passed and whether their earlier exam meets USCIS requirements. The overlap between these different exams confuses a lot of applicants, and mixing them up is one of the reasons people end up with RFEs they did not expect.
When to Involve an Attorney
Most RFEs for medical exams are straightforward. USCIS wants a form you did not submit, or the one you submitted has expired or has an error. You fix it, send it back, and the case moves forward. In these situations, you can often handle the response yourself without legal help.
The cases where an attorney earns their fee involve Class A findings, substance use disclosures, or situations where the RFE language suggests the officer is considering a denial on health-related inadmissibility grounds. If your RFE references a specific section of the Immigration and Nationality Act or asks for evidence related to a waiver, that is a signal that the stakes are higher than a routine paperwork fix. An attorney can help frame the response, coordinate with the civil surgeon on how findings are documented, and ensure that you do not inadvertently make a damaging admission in your response.
Even in less urgent situations, if you are confused by the RFE language or unsure what USCIS is actually asking for, a consultation with an immigration lawyer can save you from submitting the wrong thing and burning your one chance to respond. Many attorneys offer flat-fee RFE response services that are less expensive than full case representation.