Form N-648 · Before Your Visit

N-648 patient information form

N-648 Patient Information

Fill in the applicant’s information before the visit. Our staff reviews it with the medical records before you arrive. A family member or caregiver may fill it in for the applicant. Enter the applicant’s name in the Full Name field.

Frequently asked questions

What kind of disabilities qualify for the N-648 citizenship waiver?

At our practice, only severe memory loss or severe cognitive impairment (trouble thinking and remembering) meets medical necessity for N-648 certification. Is the memory loss or cognitive impairment mild or moderate? Then the applicant will not qualify. We will not accept the case. Fill in this form only when the impairment is severe. Then schedule the N-648 evaluation.

Can a family member fill out the N-648 patient form for the applicant?

Yes. A family member or caregiver may complete this patient information form for the applicant. Put the applicant’s name in the Full Name field, not your own. Fill it in before the visit. That is because our staff reviews it with the applicant’s medical records before you arrive.

What happens after I submit the N-648 patient information form?

Our staff reviews the information with the applicant’s medical records before you arrive for the visit. Has the evaluation not been booked yet? Schedule it on our N-648 scheduling page, text (314) 886-5902, or call (314) 960-9100. On a phone, open the form full-screen in a new tab. That makes it easier to fill in.