Visa Options for International Medical Graduates
An "alien" is any person not a citizen or national of the U.S. All visa holders, non-visa holders, and permanent residents (that is, green card holders) are classified as aliens. An immigrant is a person who is a lawful, permanent resident of the U.S. This classification does not include persons with temporary visas. A nonimmigrant is a person who has been issued a temporary visa by a U.S. consular officer (if abroad) or other authorized official (if in the U.S.).
B-1 (Temporary Visitor for Business)
B-1 visas are available to (1) IMGs or international medical students (IMS) who are coming to the U.S. to take an elective course at an American medical school or hospital that is part of their formal medical education, (2) IMGs who come to the U.S. to observe medical practices, to consult with other physicians on the practice of medicine, or both, and (3) IMGs desirous of coming to the U.S to interview for GME positions. A B-1 nonimmigrant may not work in the U.S. and cannot participate in any patient care. Generally, a person may not remain in the U.S. with a B-1 for more than one year.
H-1B (Temporary Worker)
The H-1B is the most preferred visa by IMGs and, if offered by a GME program, can often be used to attract the most qualified candidates. Foreign Medical Graduates or FMGs may use the H-1B category if:
they are undertaking teaching or research; or
they are performing direct patient care (either as interns or residents as part of graduate medical education, or in a private medical practice or private or public health care institution), provided several conditions are met.
The alien doctor must have passed the Federation Licensing Examination (FLEX) (parts I and II).
Equivalent examinations designated by the Secretary of Health and Human Services include the National Board of Medical Examiners certifying examinations (parts I, II, and III) and the United States Medical Licensing Examination (steps 1, 2, and 3);
The doctor is competent in oral or written English, as demonstrated by passage of the English language proficiency test given by the ECFMG (Educational Commission for Foreign Medical Graduates), which currently sponsors foreign doctors for graduate medical education in the J-1 category;
The doctor has a full and unrestricted license to practice medicine in a foreign state or he or she has graduated from a medical school in a foreign state; and
He or she has a license or other authorization required by the state of intended employment to practice medicine (if the state requires such a license or authorization).
If an IMG has not passed the necessary examinations, he or she may still enter the U.S. under the "researcher/teacher" classification, which specifies that the employer must certify that any patient care will be incidental to the IMG’s research. After coming to the U.S. and passing the necessary examinations, a "researcher/teacher" IMG may legally change his or her H-1B classification to "medical resident."
The H-1B visa can be granted for a maximum of 6 years. As of the date of this article, IMGs who will be employed in a research or GME capacity by (i) institutions of higher education, (ii) their related or affiliated non-profit entities, (iii) nonprofit research organizations, or (iv) governmental research organizations are exempt from the number of H-1Bs that may be granted annually (195,000 for fiscal year 2001). Once a petition filed by an employer is approved, the IMG (other than citizens of Canada) must apply for an H-1B visa at a U.S. consulate. If the IMG is in the U.S. under some other visa status (such as B-1/B-2, F-1, and so forth) the IMG’s status may be adjusted to H-1B in the U.S.
FMGs seeking H-1B status must comply with identical procedures applicable to other professionals seeking H-1B classification. Their employer must file a petition for H-1B status with the INS, and the petition must be supported by a labor condition application (LCA). Furthermore, once the petition is approved, the FMG must obtain a visa from a U.S. consulate prior to admission to the United States.
The H-1B petition for an FMG must be submitted to the INS with the following:
A company letter stating the specialty occupation of the beneficiary and containing a full description of the nature of the duties which the beneficiary will be performing, the anticipated length of stay and the arrangements for remuneration.
A copy of the LCA certified by the DOL .
Evidence that the FMG passed the Parts I and II of the Federal Licensing Examination (FLEX) or an equivalent examination (Steps 1, 2, and 3 of the U.S. Medical Licensing Examination (USMLE) or Parts I, II, and III of the National Board of Medical Examiners certifying examinations (NBME)).
Evidence that the alien has competency in oral and written English.
Evidence that the resident/physician position to be filled by the FMG is a specialty occupation.
Evidence that the FMG has a license or authorization required by the state of intended employment, if the state requires such license or authorization.
Evidence that the physician has a full and unrestricted licensure to practice medicine in a foreign state or has graduated from a medical school in the United states or in a foreign state.
The employment contract (because a written contract is not required, a summary of an oral understanding can be substituted).
Evidence of the alien’s status during past six years if within U.S. during this time.
J-1 (Exchange Visitor)
The U.S. Department of State has designated the Educational Commission for Foreign Medical Graduates (ECFMG) as the visa sponsor for all J-1 exchange visitor physicians who participate in clinical training programs. The J-1 visa is the most common visa for IMGs.
General Eligibility & Requirements
Foreign national physicians seeking J-1 sponsorship to enroll in programs of graduate medical education (GME) or training in the United States must fulfill a number of general requirements, which are detailed in the application materials. At a minimum, applicants must:
- Have passed Step 1 and Step 2 Clinical Knowledge (CK) of the United States Medical Licensing Examination™ (USMLE™) [and/or an acceptable combination of components of the former Foreign Medical Graduate Examination in the Medical Sciences (FMGEMS), the National Board of Medical Examiners® (NBME®) Part sequence, or the Visa Qualifying Examination (VQE)];
- Hold a valid Standard ECFMG Certificate at commencement of training;
- Hold a contract or an official letter of offer for a position in a program of graduate medical education or training that is affiliated with a medical school;
- Provide a Statement of Need from the Ministry of Health of the country of most recent legal permanent residence, regardless of country of citizenship.
This statement provides written assurance that the country needs physicians trained in the proposed specialty and/or subspecialty. It also serves to confirm the applicant physician's commitment to return to that country upon completion of training in the United States, as required by Section 212(e) of the Immigration and Nationality Act, as amended.
Exchange visitor physicians must maintain J-1 status by applying to ECFMG for renewed visa sponsorship, typically on an annual basis. Through this process ECFMG reevaluates the physician's continued eligibility to participate in the J-1 Exchange Visitor Program.
To ensure that approved training begins and continues as scheduled, physicians and host institutions should allow adequate time for the processing of required immigration and GME authorizations. This processing time, which begins with the foreign national physician's application for sponsorship, varies widely and may range from several weeks to months. Additionally, the U.S. Government continues to review its visa procedures, which may affect processing time.
ECFMG facilitates J-1 visa sponsorship through the coordinated efforts of training institutions and foreign national physician applicants. ECFMG verifies that the foreign national physicians meet J-1 eligibility requirements. The host institution is responsible for providing the J-1 physician with the approved clinical training. Each host institution designates a Training Program Liaison (TPL) who serves as the official representative to communicate with ECFMG. This communication ensures regulatory compliance and provides the required administrative oversight for J-1 physicians. Communication regarding all aspects of J-1 sponsorship must be conducted through the TPL. Immediately after obtaining a training contract, the foreign national physician should initiate the sponsorship process by contacting the TPL at the host institution.
Effective January 30, 2003, the U.S. Government implemented the Student and Exchange Visitor Information System (SEVIS). SEVIS is a national, web-based tracking system designed to assist educational institutions and government agencies in managing foreign national student and exchange visitor data. As a designated visa sponsor, ECFMG is required to process J-1 visa sponsorship through SEVIS.
Upon establishing an applicant's eligibility, ECFMG issues Form DS-2019, Certificate of Eligibility for Exchange Visitor (J-1) Status. The physician may also request Form DS-2019 to enable dependents (spouse and unmarried, minor children) to apply for J-2 dependent status. Issuance of Forms DS-2019 indicates that the physician and dependents are eligible to apply for the J visa. Agencies of the U.S. Government make decisions regarding the issuance of visas. The DS-2019 is one of many factors considered by the U.S. Government in determining whether to issue the visa. Policies and procedures of the U.S. Government vary and are subject to change. J-1 physicians and J-2 dependents are responsible for complying with all U.S. laws and regulations pertaining to foreign nationals. A summary of selected regulations follows.
Duration of Participation
The duration of participation for J-1 physicians in graduate medical education is the "time typically required" to complete the program. This generally refers to the minimum number of training years required by an American Board of Medical Specialties (ABMS) member board for specialty or subspecialty certification and/or the accredited length of training as defined by the Accreditation Council for Graduate Medical Education (ACGME). Duration is further limited to seven years, provided that the J-1 physician is advancing in an approved program of graduate medical education or training. The J-1 visa, however, does not entitle J-1 physicians to seven years of sponsorship. J-1 physicians are encouraged to consult with ECFMG regarding proposed educational pathways and sponsorship eligibility.
Associated training/employment authorization is specific to the approved activities stated on Form DS-2019. A Form DS-2019 obtained for a particular program may be used only for that program and is not transferable to another institution or program. Federal regulations prohibit work, training, and/or financial compensation for activities that are outside of the approved Exchange Visitor Program.
Two-Year Home Country Physical Presence Requirement
In accordance with Section 212(e) of the Immigration and Nationality Act, as amended, all J-1 Exchange Visitors who are sponsored by ECFMG for the purpose of graduate medical education or training (and all accompanying J-2 dependents) are automatically obligated to return to their country of most recent legal permanent residence for an aggregate of at least two years. At the initiation of J-1 sponsorship, the J-1 applicant declares his country of most recent legal permanent residence and submits the corresponding Statement of Need, thereby committing to return to that country. The 212(e) obligation may not be fulfilled in a different country. An individual must fulfill (or obtain a waiver of) this obligation before being eligible for a change or adjustment of visa status to certain types of U.S. visas. These visa types include: H (temporary worker), L (intra-company transferee), and U.S. permanent resident.
Many J-1s are subject to a two-year foreign residence requirement upon the completion of their training. This rule is strictly enforced wherein the J-1 visa holder must return to his or her country for at least 2 years before being allowed to re-enter the United States in another visa category. Many J-1 visa holders, however, try to have the 2-year rule waived. Not surprisingly, this is difficult. The following are the only statutory grounds for an IMG to obtain a waiver of the 2-year foreign residence requirements:
Pursuant to a recommendation by an interested federal agency or a state department of health to the INS
Upon the issuance of a "No Objection" letter from the J-1's home country (not applicable to IMGs who were issued J-1s for GME purposes)
Upon a showing that the J-1 will face persecution upon returning to his or her home country
Upon a showing that a U.S. citizen or permanent resident spouse and/or child would face "exceptional hardship" were the J-1 required to fulfill the 2-year foreign residence requirement
J-1s are required to work in federally Designated Health Professional Shortage Areas to be eligible for a waiver. The agencies that most frequently act as interested federal agencies are the U.S. Department of Agriculture and the Appalachian Regional Commission. In addition to USDA and ARC, other federal agencies, most notably the U.S. Health and Human Services Administration, can act as an interested agency. Finally, each state is empowered to recommend up to 20 waivers. Each agency had its own waiver application guidelines and should be consulted on a case-by-case basis.
O-1 (Alien with Extraordinary Ability)
Given the difficulty of J-1 waivers, IMGs and their employers often look to the O-1, which is the only relevant visa that a J-1 who is subject to the foreign residence requirement can apply for. To qualify for O-1 status, one must demonstrate sustained national or international acclaim and recognition for achievements in the field of expertise. This is established by receipt of nationally or internationally recognized prizes or awards, membership in associations field which require outstanding achievements of their members, published material in professional publications or major media about the alien concerning the alien’s work in the field, participation on a panel, or individually, as a judge of the work of others in the field, scientific, scholarly, or business-related contributions of major significance in the field, authorship of scholarly articles in the field in professional journals or other major media, employment in a critical or essential capacity for organizations and establishments that have a distinguished reputation, high salary or other remuneration commanded by the alien for services and other comparable evidence. There is no explicit statutory limitation on the period of stay for an O-1.
Optional practical training
It is work authorization for an F-1 student. It can be full- or part-time during a vacation term, part-time while classes are in session, full- or part-time after completion of coursework and while working on a thesis or dissertation, or full-time after completion of studies. It is endorsed by the F-1 student's school and authorized by USCIS.
Maximum Stay: 12 months per level of study, e.g. 12 months after Bachelor's Degree, another 12 months after Master's Degree, etc.
Processing Time: Usually 3-4 months.
Eligibility: After nine months in lawful non-immigrant status.
Restrictions/Limitations: Employment must be related to the field of study and commensurate with the level of study.
Employer is not involved in the application process.
Authorization is not employer specific.
Time limit is strict.
USCIS approval takes time.
Dependents: Spouse and minor children are granted F-2 status which does not allow study or employment.
The Green Card (Alien Registration Receipt Card) is obtained upon the approval of the immigrant visa or the adjustment of status. This Permanent Residency can be obtained through Family Sponsorship, Labor Certification through employer in the U.S., by National Interest Waiver or other special category for persons of Extraordinary Ability or the Green Card Lottery (Diversity Visa). With a Green Card, the applicant can work legally in the U.S. and it is proof of lawful residence within the U.S.
Family based Immigration
Marriages within the United States
The U.S. citizen needs to submit a visa petition to the appropriate local USCIS office or the Regional Service Center to prove that the marriage was not entered into for the sole purpose of obtaining a green card. (Effective since November 29, 1996, the application is now submitted to the USCIS Regional Service Center for processing for Maryland residents, and to the local USCIS office for everyone else.) The burden is on the parties to establish the bona fides of the marriage.
At the same time, the non-citizen spouse should submit an application for adjustment of status, green card-type photographs, and numerous other USCIS forms, plus USCIS filing fees.
The USCIS schedules an interview and the timeframe depends upon the location. The Service Centers take about 90 days for the employment card (EAD) and local office processing times for EADs range from 1 to 90 days. If the interview occurs within 90 days, it is possible that no work or travel permit will be issued.
Marriages Outside the United States
The non-citizen spouse usually must remain in her/his country until s/he obtains the green card. On the other hand, if the parties are not yet married, then the foreign fiancé/e can enter the U.S. on the K-1 fiancé/e visa but is required to get married to the sponsoring U.S. citizen and file the adjustment of status application package for the green card within 90 days of entry.
If the marriage takes place abroad, then, after the marriage, the citizen spouse submits a visa petition to either the appropriate USCIS office or directly to the U.S. embassy or consulate in the country where the non-citizen spouse lives. Embassies / consulates may impose various restrictions on who is eligible to file petitions there. Depending on the location, it could take several months to obtain the approval.
Once the visa petition has been approved, the non-citizen spouse will receive a packet from the National Visa Center (NVC). The packet will inform that spouse of the various documents required at the immigrant visa interview abroad and the packet will also include documents requesting biographic data that need to be completed and forwarded to the U.S. embassy or consulate abroad. The process can take a further three to six months.
In order to expedite the immigrant visa process after filing the visa petition (I-130), the U.S.-citizen spouse can also file a K-3 petition. As with the immigrant visa process, NVC notifies the consulate of the approval of the K-3 petition. Often the spouse is able to come to the U.S. on the K-3 in only half the time it would take to wait for the whole immigrant visa process to be completed.
In order to avoid a long separation, sometimes the spouse returns to the U.S. after marriage, depending upon the type of visa for which s/he may qualify, and files the necessary applications only after they are both in the United States. However, depending upon what type of visa is used, it is common for the USCIS to stop the non-citizen spouse at the border and exclude him/her from entering the U.S. on the ground that s/he is an intending immigrant. Since spouses of U.S. citizens are considered "immediate relatives" under immigration laws, they are exempt from all numerical quota limitations for the green card, so there is no waiting list.
If the marriage is less than two years old when the non-citizen spouse becomes a permanent resident, the green card will expire after a two-year period. Both spouses must submit a joint petition to remove the two-year condition within the 90-day period immediately preceding the end of the two-years.
If the marriage has terminated by reason of divorce, death of the citizen spouse, or spousal abuse, the non-citizen spouse may apply for a waiver of the joint petition requirement.
Immediate Family Members
Immediate relatives of U.S. citizens are: spouses, children, and parents. In this case "children" are defined as unmarried and under 21 years of age. For parents of a U.S. citizen, the petitioning son or daughter must be at least 21 years of age.
The definition of "immediate relative" includes widows of U.S. citizens, provided that the alien was the spouse of the citizen for at least 2 years prior to the citizen's death and was not legally separated from the citizen at the time of his/her death.
NB : The petition for permanent residence has to be filed within 2 years after the citizen's death and before re-marriage.
The advantage of qualifying as an immediate relative is that there is no numerical limitation or backlogs for sponsorship.
The Family preference categories are as follows:
1st Pref - unmarried sons and daughters (any age) of U.S. citizens,
2nd Pref - spouses and unmarried sons and daughters of lawful permanent residents,
3rd Pref - married sons and daughters of U.S. citizens
4th Pref - brothers/sisters of U.S. citizens.
At present the waiting time frames for the 4th preference siblings of U.S. citizens is approximately 10-12 years
RIR and NIW
As a physician eligible for a J-1 waiver, you have two possible avenues to apply for an immigrant visa, based on either a "Reduction in Recruitment (RIR) Labor Certification" or a "National Interest Waiver (NIW)." You can file on either or both of these bases.
RIR Labor Certification.
The RIR labor certification is a three-step process, in which we file first with the Department of Labor (DOL), and then with the Immigration and Naturalization Service (INS).
Step 1. Before filing with the DOL, your employer must recruit for your position. This generally involves at least one print advertisement and advertising on "America's Job Bank," a web site established by DOL. We have to file the RIR with the DOL within six months after publication of the print advertisement(s). We will work with your employer on the placement of this advertising. Our filing with the DOL includes a recruitment report, in which we demonstrate that no qualified U.S. workers responded to this advertising who were qualified and willing to assume this position. This RIR is filed with the state DOL office, which then forwards it to the U.S. DOL office. This process can take from about four months to up to two years, depending on backlogs at the state and U.S. DOL offices with jurisdiction over your place of employment.
Step 2. After your RIR is certified by the U.S. DOL, we file that approved labor certification as part of your immigrant visa petition (form I-140) with the INS. This is a fairly straightforward filing in which we demonstrate that your employer is a qualifying U.S. employer and is able to pay your wage, and that you qualify for the position. INS processing times for the form I-140 vary, but generally are between three and eight months.
Step 3. After the form I-140 is approved, you either can process for your visa at a U.S. consulate abroad or file an application with INS to adjust your status in the United States. There are benefits and drawbacks to each of these, and we can discuss which would be better for you. There are a few general rules, however. If you consular process, you cannot receive your immigrant visa abroad until you have completed your three years in H status required by your J-1 waiver, your spouse and dependent children receive no travel or work authorization until they return to the United States as permanent residents, and you must remain employed by your sponsoring employer until you return in immigrant status, and for some period of time thereafter. If you file with INS to adjust your status in the United States, you cannot file to adjust until you have completed your three years in H status required by your J-1 waiver, your spouse and dependent children can receive travel and work authorization during the pendency of your adjustment application, and you must remain employed by your sponsoring employer either (1) until the adjustment is approved and for some period of time thereafter, or (2) for at least six months after filing your adjustment application, whichever occurs sooner. .
The INS recently has implemented a policy that individuals can file adjustment applications concurrently with filing an I-140 petition. However, since a J-1 waiver physician, whose form I-140 petition is based on a labor certification cannot file an adjustment application until he or she has completed three years in H status, it is unlikely that most J-1 physicians can take advantage of this concurrent filing policy.
National Interest Waiver (NIW).
To be eligible for an NIW, a physician must agree to work full-time (40 hours a week) in a clinical practice for a total of five years. The clinical practice must be located within an area that is designated as a Medically Underserved Area (MUA), a Primary Medical Health Professional Shortage Area (HPSA), a Mental Health Professional Shortage Area (MHPSA), or within a Veterans Affairs (VA) facility. Further, a physician serving in a MUA, MHPSA, or HPSA must provide services in a medical specialty for which the area is designated. For example, a physician who received a J waiver through the VA based on specialty practice likely could not leave the VA system after the initial three-year service obligation to work in a HPSA, because HPSAs are only designated for primary care.
Additionally, a physician must accumulate the required five years of medical service within the six-year period beginning on the date the NIW is approved (Form I-140). If a physician has obtained a J-1 waiver and changed to H-1B nonimmigrant status, however, the physician will begin accumulating the required five years of service on the date the physician changes from J-1 to H-1B status, not on the date of I-140 approval. No time spent in J-1 classification counts towards meeting the five-year requirement.
The NIW is a two-step process filed exclusively with the INS, without any DOL filing. The basis for the filing is that your work in a Health Professional Shortage Area ("HPSA"), a Medically Underserved Area ("MUA") or at a Veterans Affairs (VA) facility is "in the national interest."
Step 1. The INS filing is also a form I-140 petition. In this filing, we demonstrate that you will be practicing full-time primary care or psychiatry in a HPSA or MUA or practicing full-time at a VA facility for a period of five years. As a physician must serve in a medical specialty for which the area is designated, and as areas generally are designated only for primary care and mental health, it may not be possible for a specialist (other than a psychiatrist) working in a HPSA or MUA to qualify for an NIW. You may need to amend your employment contract to provide a five year term, and to provide INS with a contract dated within six months of filing. If you intend to be self-employed after your three-year period in H status is completed, we would need to provide INS with a statement of your plans for self-employment. We also need to provide INS with a statement from the health department of the state in which you will be practicing or the VA that your work in that HPSA or MUA is in the public interest. INS regulations authorize a physician to change employers or become self-employed during the five-year service period, as long as the physician continues to work in a HPSA or MUA, or at a VA facility. A new I-140 may be required, but the five-year commitment period does not start over. INS regulations do not address whether a physician can serve part of this time in a HPSA/MUA and part of the time at a VA facility.
Step 2. Physicians qualifying for an NIW cannot receive their immigrant status until the completion of their five-year commitment. The INS has taken the position that NIW physicians cannot consular process but must file applications to adjust status. Unlike RIR applicants, physicians applying for an NIW need not wait for the end of their three year period in H status before filing for adjustment, but can file adjustment applications either concurrently with the form I-140 or at any time thereafter. Spouses and dependent children can file for travel and work authorization while the adjustment applications are pending. The J-1 waiver physician can file for travel and work authorization after the three-year H period is completed. The adjustment application will not be approved until the completion of the five-year NIW commitment. The three years a J-1 waiver physician serves in H status are included in this five-year period. This five-year commitment must be completed within six years of commencing work in H. At the end of the five-year period, the physician must submit evidence to INS that he or she has fulfilled this requirement. Required documentation includes copies of the physician's W-2 forms and tax returns for the five-year period, and either (1) a letter from the physician's employer attesting to the full time practice, or (2) if the physician is self-employed, documentation of the physician's private practice. After submission of this evidence, INS will schedule the physician for fingerprinting. It is uncertain what INS's processing time for approval is after submission of this evidence.
Green Card Lottery
Since October 1994, there has been an annual permanent lottery program in place (Diversity Visa Lottery Program). India and Pakistan, however, are excluded because they are over-represented among immigrants in the U.S. Persons born in Bangladesh as well as many other countries do qualify. Natives of India or Pakistan may apply only if, for example, they were born in what was India but is now Bangladesh, or born in any country that is eligible to participate in the lottery program, or if they are married to someone who is eligible to apply for the lottery under the principle of cross-chargeability. Certain other narrow exceptions may also apply.
Lottery visas are distributed among six geographical regions. A greater proportion of visas goes to those regions with lower immigration rates in the U.S. The regions are :
Africa : All countries on the continent of Africa and adjacent islands.
Asia : From Israel to all North Pacific Islands, including Indonesia.
Europe : From Greenland to Russia - includes all countries of the former Soviet Union.
North America : Tends to include only one qualified country, The Bahamas.
Oceania : Includes Australia, New Zealand, Papua New Guinea, and all countries and islands in the South Pacific.
South America : Includes Central America, Mexico and the Caribbean countries.
Individuals born in countries that have significant numbers of immigrants to the United States are considered "high admission" and are not eligible for the program. "High admission" countries are defined as those from which the United States has received 50,000 or more immigrants during the last five years in the immediate relative, or family, or employment preference categories. The high admission countries vary from one year's lottery to the next.
Requirements : In addition to being born in a qualifying country, applicants must have either a high school education or its equivalent, or within the past five years have two years of work experience in an occupation that requires at least two years of training or experience.
Only one entry for each applicant may be submitted during the registration period. Duplicate or multiple entries will disqualify individuals from registration for this program.
Entries received before or after the specified registration dates, regardless of postmark, and entries sent to an address other than one indicated in the Department of State’s instructions are all void. All entries received during the registration period will be individually numbered. Entries will be randomly selected by computer, regardless of the time of receipt. Only successful registrants will be notified by mail at the address listed on their entry.
No outside service can improve an applicant's chance of being chosen or guarantee an entry will win and any service that claims it can, is promising something it cannot deliver. Outside agencies can only help in the proper filing of the application - paying attention to the details involved
Visa Options for International Medical Graduates