I-693 Medical Exam: File It With Your I-485, or USCIS Rejects the Whole Package

Since December 2, 2024, an I-485 filed without Form I-693 may be rejected outright. Not an RFE — a rejection, fee returned, filing date gone. Here is what has to be in the envelope.

You are holding a returned envelope. Inside is the I-485 package you spent three weeks assembling, your uncashed check or a refund notice, and a rejection notice that does not read like a denial and does not explain what to do next. Somewhere in the paperwork is a line about Form I-693.

Here is the rule that caused it. Effective December 2, 2024, if you are required to submit Form I-693, Report of Immigration Medical Examination and Vaccination Record, you must submit it with your Form I-485 — and USCIS says that otherwise it may reject your Form I-485. That language is printed on the Form I-693 page and repeated on the Form I-485 page.

The advice that gets people rejected is not stupid advice. It used to be correct. For years, the standard move was to file the I-485 without the medical, wait for USCIS to issue a Request for Evidence, and send the sealed envelope in response. Thousands of people did it. It is still the top answer on forums and still sitting in law-firm posts that have not been updated. It stopped working on December 2, 2024.

This guide covers what has to be in the envelope, who is exempt and who only files part of the form, how long a completed I-693 stays good, how to sequence the exam against the Visa Bulletin, and what to do if your package already came back.

What changed on December 2, 2024

USCIS moved the medical exam from a mid-case evidence item to a filing requirement. The reason is administrative: RFEs for missing medicals were adding months to adjustment adjudication, and the agency decided to stop receipting incomplete packages instead of chasing them.

The requirement is carried on the form itself, which is why form editions matter here more than usual:

• Form I-485. The current edition is 01/20/25. USCIS notes that if any of the form's pages are missing or are from a different form edition, it may reject the form.
• Form I-693. The current edition is also 01/20/25. The cutover has already happened: if the civil surgeon signed on or before July 2, 2025, either the 03/09/23 or the 01/20/25 edition is acceptable; if the civil surgeon signs on July 3, 2025 or later, USCIS will accept only the 01/20/25 edition. The USCIS Policy Manual puts it plainly: in most cases the only acceptable edition is the one in use at the time the civil surgeon signs.

Check both edition dates at uscis.gov/i-485 and uscis.gov/i-693 in the week you file. Editions change, and a superseded edition is its own rejection reason independent of the medical exam.

Rejection versus denial versus RFE

These three words get used interchangeably and they are not the same event. The difference is the whole reason this rule is dangerous.

If you are trying to work out which one you got, the tell is the receipt number. A rejection does not produce one. For the distinction between the two mid-case notices, see our guide to the difference between an RFE and a NOID.

Why a rejection is worse than it sounds for employment-based filers

A denial is a bad outcome you can sometimes fight. A rejection is a non-event that quietly undoes everything downstream of the filing. For someone on the EB-2 or EB-3 track, "you never filed" means all of the following at once:

• No pending I-485. Nothing to point to, nothing to travel on, nothing to port.
• No concurrent I-765 or I-131. If you filed employment authorization and advance parole with the package, they come back too. The whole envelope comes back as one unit. That is the part people underestimate — you did not lose one form, you lost three, plus the fees on each until they are returned.
• No 180-day clock. Your I-140 portability clock under AC21 never starts, because it runs from the pending adjustment application. See AC21 portability after your I-140 is approved.
• No biometrics appointment. The Application Support Center notice only issues on a receipted case. If you were counting weeks from filing to your biometrics appointment, reset the count to zero.
• No advance parole. If the plan was to travel on advance parole rather than a visa stamp, that plan is now dependent on a filing that does not exist. Our guide to travelling on advance parole while adjustment is pending explains what you are giving up.

And the one that turns an inconvenience into a multi-year problem: if your priority date retrogresses in the next Visa Bulletin, you may not be able to refile for months or years. The filing window is not a personal deadline you can miss and pick up later. It is a chart that moves. Our guide to how to read the Visa Bulletin and your priority date covers how far and how fast that chart can move against you.

Fees, at least, come back. For what each of these filings costs when you do refile, see our 2026 USCIS fee breakdown. As of Form G-1055 edition 05/29/26, the I-485 fee for an applicant over 14 is $1,440 by mail or $1,390 online.

Who actually has to file an I-693

Do not reason from your own case to a general rule, and do not reason from a general rule to your own case. Read the Form I-693 instructions for your category.

The structure is narrower than most summaries suggest. There is no broad category of adjustment applicant who files nothing. What exists is a set of categories who file a partial Form I-693 — Parts 1 through 5, Part 7, and Part 10, the Vaccination Record — because they already completed an immigration medical examination with a panel physician abroad. USCIS lists them:

• Refugees (Form I-590 or Form I-730) who already completed a panel physician examination outside the United States.
• Derivative asylees (Form I-730) who already completed a panel physician examination outside the United States and applied for adjustment within one year of eligibility to file.

And a second set who file the partial form only if the vaccination record was not properly completed as part of the overseas panel physician examination:

• K-1, K-2, K-3 and K-4 nonimmigrants — spouses, fiancé(e)s and their children — who completed a panel physician examination no more than one year before filing to adjust.
• Afghan nationals who arrived under Operation Allies Welcome and already completed a panel physician examination abroad.

USCIS adds a caution worth reading twice: if an overseas examination revealed a Class A medical condition, or there is reason to believe you acquired one after admission or parole, you may need a new examination regardless.

The practical rule for this site's readers: if you are adjusting from F-1, OPT, STEM OPT, H-1B, H-4 or L-2 on an employment-based petition, assume you need the full Form I-693 and build your timeline around it. None of the partial-filing categories above describes you. Where the I-485 sits in the wider three-step path is covered in our PERM to green card guide for H-1B holders, and the petition that has to be approved or concurrently filed first is walked through in every stage of the I-140.

What the civil surgeon actually does

Clinic marketing pages describe this as a physical. It is a specified federal protocol with a defined test panel, and knowing the protocol is how you avoid losing two weeks.

Finding a civil surgeon

Only a physician USCIS has designated as a civil surgeon can complete Form I-693. Use the USCIS Find a Civil Surgeon tool, which lets you filter by location, languages spoken, and physician sex. Only doctors of medicine (M.D.) and doctors of osteopathy (D.O.) who are currently licensed may be designated, and the Policy Manual requires the physician to hold the designation at the time the examination is completed — not when you booked it.

Your own doctor cannot do this unless they appear on that list. Two blanket designations exist: military physicians at military treatment facilities, for eligible service members, veterans and dependents; and state and local health departments, which are recognised as civil surgeons for the limited purpose of completing the vaccination assessment for refugees seeking adjustment.

On cost: USCIS does not regulate what civil surgeons charge, and rates vary by clinic. USCIS says so directly and suggests calling several to compare. There is no government-published figure, so any dollar range you read online is somebody's anecdote. Call three clinics in your metro and ask for a good-faith estimate that separates the examination fee from the cost of any vaccines you still need.

What the exam covers

A physical examination and medical history review, plus a specified laboratory panel set by the CDC's Technical Instructions for Civil Surgeons. The age-based triggers as CDC currently publishes them:

• Tuberculosis. An interferon-gamma release assay — an IGRA blood test — for all applicants aged 2 and older. A positive IGRA, known HIV infection, or signs or symptoms of TB disease requires a chest x-ray.
• Syphilis. All applicants aged 18 to under 45 are tested. Outside that range, only where there is reason to suspect infection. Nontreponemal and treponemal tests must be run on the same blood sample.
• Gonorrhea. All applicants aged 18 to 24 are tested by nucleic acid amplification test. Outside that range, only where there is reason to suspect infection.

⚠️ You cannot bring your own lab results. CDC's instructions require that these tests be ordered by the civil surgeon at the time of the immigration medical examination. Testing performed elsewhere, or performed before the civil surgeon examines you, is not acceptable. This is the single most common way applicants lose a week they thought they had saved — you turn up with a recent TB test from your primary care physician and are sent to the civil surgeon's lab anyway. Budget for the turnaround.

The civil surgeon also reviews the mental health and drug abuse or addiction grounds. Those are two of the four health-related grounds of inadmissibility under INA 212(a)(1): a communicable disease of public health significance, failure to document required vaccinations, a physical or mental disorder with associated harmful behaviour, and drug abuse or addiction.

If any part of your examination produces a finding — a positive TB result, a reactive syphilis or gonorrhea test, a mental health history, or any prior drug-related arrest or treatment — stop reading general guides and speak to an immigration attorney before you file. A Class A condition can make you inadmissible and may require a waiver on Form I-601. The Policy Manual is explicit that a civil surgeon may annotate a Class A condition and still certify the form, in which case the officer determines inadmissibility and invites a waiver request. That is not a checklist problem. It is a case with a legal question in it.

Vaccinations

The required list comes from the INA and from CDC, and USCIS publishes it on its Vaccination Requirements page. As currently published, immigrants and adjustment applicants must be vaccinated against:

mumps; measles; rubella; polio; tetanus and diphtheria toxoids; pertussis; Haemophilus influenzae type B; hepatitis B; and any other vaccine-preventable disease recommended by the Advisory Committee on Immunization Practices that CDC has determined should be required for immigration purposes.

Two details that change how you schedule:

• You are only required to document vaccines that are age-appropriate for you. The civil surgeon annotates the form where a vaccine was not age-appropriate.
• Seasonal influenza is required only when available. The civil surgeon administers the flu vaccine from September 1 to March 31. If your examination falls outside that window and the vaccine is not available to your civil surgeon, you are not required to document it.

And the detail that contradicts a lot of published timeline advice: you are only required to receive a single dose of each vaccine at the visit. USCIS states that once you have received the single dose appropriate at the time, the civil surgeon can sign and certify the Form I-693, and encourages you to complete the series with your own provider afterwards. A multi-dose catch-up series is not a reason to delay filing.

COVID-19 is gone. Effective January 22, 2025, USCIS waived any and all requirements that adjustment applicants document COVID-19 vaccination on Form I-693, stated it will not issue an RFE or Notice of Intent to Deny on that basis, and stated it will not deny an application for failing to document it. If a guide or a clinic tells you to get a COVID shot for your green card medical, that guide is more than eighteen months out of date. Every other vaccine on the list above still applies.

Waivers exist for individual vaccines where there is a medical contraindication or the vaccine is not age-appropriate; the civil surgeon annotates the form. A waiver on religious or moral grounds is narrower than most people assume: USCIS requires that you be opposed to all vaccinations in any form — an objection to one specific vaccine will not do — that the objection be based on religious beliefs or moral convictions, and that those beliefs be sincere. It is claimed on Form I-601 for I-130 or I-140 based adjustment, or Form I-602 for refugees and asylees. If that is your situation, this is an attorney's filing, not a form you complete on your own.

The sealed envelope, and the exception that is new

The classic rule: the civil surgeon completes and signs the form, seals it in an envelope, and hands it to you. Do not accept it if it is not sealed. You — not the civil surgeon — submit it to USCIS, and USCIS will not accept a form in an envelope that has been opened or altered.

That is still exactly right if you file on paper. It is no longer the whole story.

⚠️ Read this before you break or protect any seal — the rule now depends on how you file. USCIS offers online filing of Form I-485 for certain applicants and representatives, and the two paths have opposite instructions. Filing by mail: nothing has changed. Submit Form I-693 with your I-485 package in the original sealed envelope from the civil surgeon, to the direct filing address for your I-485. Filing online: USCIS instructs you to open the sealed envelope yourself and upload the completed Form I-693 with your application package — then keep the original form and the envelope until USCIS makes a final decision on the I-485, because it may review them at an interview or ask you to submit them as evidence. Confirm which path applies to you on the Form I-693 page before you do anything irreversible, and if an attorney is filing for you, ask them which path they are using.

Whichever path you are on, ask the civil surgeon for a duplicate copy for your own records at the time of the examination. You want to know what is on that form without ever having to decide whether you are allowed to look.

How long a completed I-693 stays good

This is the section with the highest error rate on the open web, because the rule changed twice and most pages stopped after the first change. Read it as a timeline.

Before April 2024. An I-693 was valid for two years from the civil surgeon's signature. Simple, and now historical.

April 4, 2024. USCIS updated the Policy Manual so that a Form I-693 properly completed and signed by a civil surgeon on or after November 1, 2023 did not expire, and could be used as evidence for any future immigration benefit application. A form signed before November 1, 2023 retained evidentiary value for two years from the signature date. The November 1 line exists for a technical reason: from that date CDC required civil surgeons to enter certain Form I-693 information into eMedical, an electronic health processing system that reports to health departments, so USCIS could trust the data to stay current.

June 11, 2025. USCIS narrowed it, in Policy Alert PA-2025-08. The agency concluded the April 2024 policy was overly broad and could threaten public health by letting applicants submit a medical tied to any previous application, including cases where results were outdated or TB treatment was never followed up. Under the current rule, a properly completed Form I-693 signed on or after November 1, 2023 can only be used as evidence for the entire period the application it was submitted with is pending. If that application is withdrawn or denied, you need a newly completed and signed Form I-693 for any future filing. The guidance is effective for applications pending or filed on or after June 11, 2025.

So the current state of play, in one line each:

• Signed before November 1, 2023: valid for two years from the signature date.
• Signed on or after November 1, 2023: no fixed expiry date, but tied to the pendency of the application it was filed with.

"Does not expire" is not the same as "is reusable." That is the sentence the rest of the internet is missing. If you withdraw an I-485 — to refile in a different EB category after a downgrade, for example — you are starting the medical over, and paying for it again. And separately from all of this, a USCIS officer retains discretion to request a new or updated Form I-693 at any time if there is reason to believe your medical condition has changed or that the form does not accurately reflect it.

Whether to withdraw a pending I-485 is a case-specific decision with a cost you now know about. Take it to an immigration attorney, not a comparison table.

Sequencing the exam against the Visa Bulletin

Work backwards from the filing month, because every step is real calendar time and none of it compresses:

1. The I-485 has to be filed inside the filing window.
2. Before that, the completed Form I-693 has to be in your hands.
3. Before that, the civil surgeon has to have your lab results back and sign the form.
4. Before that, the labs have to be drawn — by the civil surgeon's order, at the time of your examination.
5. Before that, you need an appointment.

Two things govern how much slack you have. First, watch the Dates for Filing chart, not only Final Action Dates. The filing chart is what governs whether you may submit an I-485 at all in a given month, and USCIS confirms each month which chart applies. Second, book the appointment before your date becomes current, not after. The vaccine series is not the long pole — the single-dose rule takes care of that. The appointment and the lab turnaround are.

The anti-pattern is specific and common: the bulletin publishes, the reader starts calling clinics, the first available appointment is eleven days out, the labs take another week, and the month closes. Nothing went wrong. The sequence was simply started too late.

What to do if your I-485 was already rejected

Calmly, in order:

1. Confirm it is a rejection. Returned forms, returned or uncashed fee, and no receipt number means the filing was never accepted. If you have a receipt number, you have something else and the remedies are different.
2. Confirm your priority date is still current under the applicable chart for the month you intend to refile. This is the step that determines whether you have a problem or an inconvenience.
3. Deal with the envelope. USCIS has published a specific accommodation for exactly this situation: if it rejects an application package and returns it with the Form I-693 envelope opened, and you want to file a new package with that original opened form, you may include the original opened Form I-693 and the supporting documentation the civil surgeon put in the envelope, together with a copy of the rejection notice. You do not automatically need a new examination because a lockbox opened your envelope.
4. Refile complete, on the current form editions. Check the I-485 and I-693 edition dates that week.
5. Understand what the rejection did and did not do. It is not a denial. It is not reported as one. It does not create an immigration violation. It also preserves nothing.

That last point is where this stops being an article's question. If you were relying on the pending I-485 for anything — an F-1 or OPT holder whose work authorization or travel plan assumed a receipted filing, or an H-1B holder near the six-year cap — the gap between the rejection and the refiling is a status-maintenance problem, and it belongs with an immigration attorney immediately. F-1 and OPT readers should also loop in their DSO on anything touching status.

Common mistakes

• Filing on a superseded form edition. Both the I-485 and the I-693 have current editions; check them in the week you file.
• Getting the envelope wrong for your filing path — mailing an opened one, or refusing to open it when USCIS's online-filing instructions tell you to.
• Using a physician who is not a designated civil surgeon, or one whose designation is not current on the day the examination is completed.
• Assuming an I-693 from a prior withdrawn or denied case can be reused. Since June 11, 2025, it cannot.
• Delaying the exam for a multi-dose vaccine series, or for a COVID-19 shot that has not been required since January 22, 2025.
• Bringing your own recent TB or syphilis results and assuming they count. They do not.
• Booking after the bulletin publishes rather than before.
• Not keeping a personal copy of the completed form. Ask at the exam.

Frequently asked questions

Do I have to file Form I-693 at the same time as my I-485?

In almost all adjustment cases, yes. USCIS states that effective December 2, 2024, if you are required to submit Form I-693 or a partial Form I-693, you must submit it with your Form I-485, and otherwise USCIS may reject your Form I-485. Rejection is not the same as a denial — USCIS returns the package and the fee unadjudicated — but you lose the filing date, which matters enormously if you filed in a month your priority date was current.

What is the difference between an I-485 rejection and an I-485 denial?

A rejection means USCIS never accepted the filing. The package comes back, the fee is returned, no receipt number is issued, and legally you never filed. A denial means USCIS accepted and adjudicated the case and said no. Before December 2024, a missing I-693 typically produced a Request for Evidence on an already-receipted case. Now it can stop the case from being receipted at all.

Does Form I-693 expire?

The rule changed twice. A Form I-693 signed by a civil surgeon before November 1, 2023 retains evidentiary value for two years from the signature date. A Form I-693 signed on or after November 1, 2023 has no fixed expiration date — but under guidance effective June 11, 2025, it is generally valid only for the entire period the application it was submitted with remains pending. If that I-485 is withdrawn or denied, the I-693 goes with it and you need a new exam for any future filing.

Do I still need the COVID-19 vaccine for my green card medical exam?

No. Effective January 22, 2025, USCIS waived any and all requirements that adjustment of status applicants document COVID-19 vaccination on Form I-693. USCIS has stated it will not issue a Request for Evidence or Notice of Intent to Deny related to proving COVID-19 vaccination and will not deny an adjustment application on that basis. Every other vaccination required under the INA still applies.

Who can perform the I-693 medical exam?

Only a physician USCIS has designated as a civil surgeon, located through the USCIS Find a Civil Surgeon tool. Only doctors of medicine and doctors of osteopathy who are currently licensed may be designated, and the physician must hold the designation on the date the examination is completed. Your own primary care physician cannot do it unless they hold that designation. Military physicians at military treatment facilities and state and local health departments hold blanket designations for limited purposes.

What happens if I open the sealed envelope?

It depends on how you are filing. If you file Form I-485 by mail, the envelope must arrive unopened, and USCIS will not accept a form in an envelope that has been opened or altered. If you file Form I-485 online, USCIS now instructs you to open the envelope yourself and upload the completed form, then keep the original form and envelope until a final decision is made. Confirm which path applies to you before you break any seal.

I am on F-1 OPT or H-1B and my priority date just became current. How early should I book the exam?

Book it as soon as you can see the Visa Bulletin movement coming, not after. Civil surgeon appointments and the required lab work take real calendar time, and the tuberculosis, syphilis and gonorrhea tests must be ordered by the civil surgeon at the time of your examination — you cannot bring results from your own doctor. The completed form has to be in your hands before you can file. Applicants who wait for the bulletin to publish routinely miss a filing month entirely.

A rejection is not a judgement about your case. It is a package that was never opened, and the only thing that fixes it is filing a complete one before your chart moves. F1Jobs works with international students and workers across the whole arc from OPT to permanent residence, including the paperwork that has to land in the right month. This article is general information, not legal advice — any medical finding, prior arrest, prior visa refusal, or already-rejected filing needs an immigration attorney, and F-1 and OPT readers should raise anything touching status maintenance with their DSO.