Immigration Guide for

Foreign Medical Professionals

A Guide for Understanding Today's
Immigration Landscape in the United States
 Immigration Guide for Foreign Medical Professionals

Part 1: Healthcare Immigration 101: What you Need to Know to Get Started
• Understanding ECMFG Certification
• Understanding the Home Residency Requirement

Part 2: Employer Sponsored Visa Petitions

• Understanding the Conrad Waiver
• Other Employer Sponsored Visa Petitions
o H-1B Visa
o O-1 Visa
o TN Visa

Part 3: Self-Sponsored Work Visas and Green Cards

• Extraordinary Ability and National Interest Waiver
• E Visa for Investment
Part 4: Planning Ahead for the PERM process
• Business sponsored Green Cards
• Self Petition Green Cards
 About This Guide
Challenges to today’s healthcare providers are complex and multifaceted. Hospitals and
healthcare facilities must navigate burgeoning patient populations as aging Baby
Boomers require increased medical care, in addition to stresses from the opioid
epidemic, and economic and demographic shifts in their communities. All these issues
are compounded by workforce shortages at every level – from nurses and clinicians to
family practice physicians to skilled surgeons.

Unfortunately, the immigration landscape in the United States has seen its own
challenges in recent years. As part of President Trump’s “Buy American, Hire
American” initiative, once routine work visa applications and green card petitions have
undergone unforeseen levels of scrutiny.

As a foreign medical graduate, it is important to understand the nuances of the visa

application process if you would like to live and work in the United States. This Guide
is an overview of everything you need to know – from certifications and visa
requirements, to the types of work visas available to FMGs, to planning for permanent
residence in the U.S.

We offer complimentary consultations

and would be happy to talk with you
about your business needs.

Call us today to set up an appointment,

at (207) 613-7334

Or e-mail michael@fordmurraylaw.com

Page 1
 Part 1: Healthcare Immigration 101: What You
Need to Know to Get Started
If you are an international medical professional who is interested in completing
your residency in the United States, you have likely wondered what steps to take in
order to make your career goal a reality. One possible solution is to become
ECFMG certified.

Understanding ECMFG Certification

The ECFMG, or Educational Commission for Foreign Medical Graduates, is a

non-profit organization which provides certification for international medical
graduates who are seeking to complete their residency or fellowship program in
the United States. An international medical graduate is any graduate who received
their medical education outside of the United States or Canada, regardless of
whether they are United States citizens or have citizenship in a foreign country.

Certification is required not only for

graduates to enter ACGME programs,
but also as a prerequisite for IMGs to
take the final step of the United States
Medical Licensing Examination.

In order to obtain ECFMG

certification, IMGs must submit an
application to ECFMG. In addition to
the application, medical science
examination and medical education
criteria must be met.

Healthcare Immigration 101 | Page 2

 Part 1: Healthcare Immigration 101 (cont.)
Medical Education Credentials Requirement
To fulfill the medical education credentials requirement, international medical
graduates must meet all the following requirements:
• Graduate from a school that is listed in the World Directory (available
online, this directory provides a list of schools whose graduates are
eligible to apply for ECFMG certification);
• Earn four years of credit from a World Directory school;
• Provide documentation that shows the following: completion of the
requirements for a medical degree, receipt of a medical degree, a copy of
the applicant’s final medical school transcripts, and transfer credit
verification if applicable;
• Provide primary-source verification of both the diploma and transcripts

Medical Science Examination Requirements

There are two medical examination requirements that international medical
graduates must fulfill:
1. the medical science examination
criteria and
2. the clinical skills requirement.

The medical science examination criteria

can be satisfied by completing the
USMLE Step 1 and Step 2 Clinical
Knowledge exams.
The clinical skills requirement is fulfilled
by passing the USMLE Step 2 Clinical
Skills exam.

Healthcare Immigration 101 | Page 3

 Part 1: Healthcare Immigration 101 (cont.)
Understanding the Home Residency Requirement
The J-1 Visa Program provides the opportunity for people outside of the country
to come to the U.S. to further their education or training. In order for J-1 visa
holders to complete their education and possibly live and work in the US
permanently, they must follow certain guidelines set forth under the J-1
requirements. One of these stipulations is the 2-year home residency
requirement, also called HRR, and it’s a crucial part of completing the J-1 visa
process.

What is the 2-Year Home Residency Requirement?

After completing studies or training in the United States, a J-1 visa holders must
return to their home country for a total of two years. The purpose of this
requirement is to foster the “exchange” component of the visa program –
allowing the J-1 holder to share and spread their new knowledge or expertise
back home.

Unfortunately, it’s not

enough to simply
leave the US and
embark on a lengthy
vacation - the visa
specifically requires
that visa holders
return to their last
country of residence
and show proof of
residence.

Healthcare Immigration 101| Page 4

 Part 1: Healthcare Immigration 101 (cont.)
J-1 visa holders are allowed to travel as they wish, including returning to the US
for a period of time, but must spend a total of two years in their home country
before planning to reside long-term in the U.S., unless an exception is found.

Who Must Fulfill the HRR?

The J-1 visa program outlines several specific scenarios in which the J-1 holder
would be subject to the HRR requirement before changing his or her immigrant
status:

• Individuals whose education

was partially or fully funded
with money from his or her
home country, including any
international organizations
who contribute financially
• Any student who was part of a
graduate medical training
during his or her J-1 program
• The field of study is included
on an Exchange Visitor Skills
List for the home country,
meaning the country could
benefit from having more
individuals with this specific
training

Healthcare Immigration 101 | Page 5

 Part 1: Healthcare Immigration 101 (cont.)
Are There Ways Around this Obligation?
Often a J-1 visa holder would like to remain in the United States after the J-1
program, perhaps to continue work or training. In this case, individuals are able
to request a waiver of the 2-year HRR, but must qualify for a waiver program:
• The home country files a “no objection” response, stating that it does not
mind if the visa holder does not return for the two-year requirement
• Family members who are US citizens would undergo extreme hardship if
the visa holder were to leave
• Returning to the country of last residence would cause the visa holder to be
persecuted based on race, religion, or beliefs
• The work of the J-1 visa holder is essential to a government agency, and the
agency produces supporting documentation the visa holder is needed in
the United States
Additionally, foreign medical graduates can seek out sponsorship of a J-1
Conrad Waiver, which we will discuss in Part 3 of this guide. If you are in the
US under the J-1 visa and are unsure if you are required to fulfill the HRR,
contact the team at FordMurray Law today. We are here to help you figure out
your next steps.

Healthcare Immigration 101| Page 6

 Part 2: Employer Sponsored Visa Petitions
The most straightforward option for a foreign physician who wishes to forgo the
HRR is the Conrad 30 J-1 Visa Waiver – a visa program administered through
state health agency which allows foreign medical graduates to work in medically
underserved areas in exchange for a waiver to the HRR requirement.

Understanding the Conrad Waiver

The Conrad 30 Program permits hospitals and healthcare employers to sponsor
FMGs for an employment period of three years in a health professional shortage
area or medically underserved area. After the period of employment, the HRR is
waived and the physician is eligible to be sponsored for permanent residence
status, or to self-petition for a green card. The details of this annual program differ
by state, but a Conrad waiver will likely be the best way for your healthcare facility
to recruit and retain highly-qualified foreign physicians.
The Conrad 30 Program runs on the federal fiscal year, so most states will begin
accepting applications between September 1st and October 1st. Each state program
receives 30 waiver slots per
year and must meet certain
federal requirements, although
each state can also create its
own standards and protocols.

In general, a Conrad waiver

application must demonstrate
that the FMG will be working
full-time in a qualifying
underserved area, and that the
FMG agrees to work for the
sponsoring healthcare facility
for at least three years.

Employer Sponsored Petitions | Page 7

 Part 2: Employer Sponsored Petitions (cont.)
Additional state-specific requirements may include letters of recommendation
and evidence of a medical license and other professional credentials. A
sponsoring healthcare facility must be in health professional shortage areas
(HPSA) or medically underserved areas (MUA), except in limited circumstances.
These include areas that are designated as having shortages of primary medical
care, dental or mental health providers, and/or areas with a specific patient
population that is underserved (based upon levels of Medicare and Medicaid
reimbursements and other factors.)

How to Apply for the Conrad 30 J-1 Visa Waiver

The Conrad 30 Waiver is employer sponsored. Employers must start the process
well in advance of the employment start date (typically the physicians graduate
from the residency or fellowship in June or July and begin work at the hospital in
July or August).

The filing window for the state

programs typically opens between
September 1st and October 1st (the
year prior to the anticipated start
date), and in larger states such as
New York, Texas, and California,
the 30 waiver slots will be exhausted
in the first weeks of availability, if
not the first day.

In other states, the slots will remain

available for several months, while
low-usage states like North Dakota
and Wyoming may not exhaust all
available slots for the entire fiscal
year.

Employer Sponsored Petitions | Page 8

 Part 2: Employer Sponsored Petitions (cont.)
Employer Criteria
The initial application is filed with the state’s Conrad 30 J-1 Visa Waiver
program, which is usually found within the state’s Department of Health and
Human Services or the equivalent. In addition to the physician criteria stated
above, the state program will want to know the following about the employer:

• Has it made a good faith effort to recruit a U.S. physician for the position?

• Does the facility have the resources and retention program in place to
retain the physician for longer than the minimum 3 year service period?

• Is the facility located in a qualifying underserved area?

Must Know Deadlines

How long does the Conrad 30 J-1 Visa Waiver application process take?

The Conrad waiver application will take several weeks to several months to
process at the state level. If approval is recommended, the application is
forwarded to the U.S. State Department’s J-1 Waiver Review Division (WRD)
in Washington, DC. The WRD will take 8 to 12 weeks to conduct its review. If
approval is recommended by the WRD, the application is transferred to the
U.S. Citizenship and Immigration Services (USCIS) for final processing of the
J-1 Waiver.

The sponsoring healthcare facility will then need to file an H-1B petition with
USCIS to change the physician’s status from J-1 to H-1B Nonimmigrant
Worker to facilitate the start of post-training work with the employer. The
physician must then serve out the 3 year period with the employer/J-1 Waiver
sponsor in order to fully waive the 212(e) two year Home Residency
Requirement. The service must be performed in H-1B visa status.

Employer Sponsored Petitions | Page 9

 Part 2: Employer Sponsored Petitions (cont.)
If you are interviewing for a position that could qualify for a J-1 Conrad Waiver,
here are some important things to know.

• Know optimal time to interview:

Interviewing foreign physicians will start the summer before expected
graduation from residency/fellowship (for example, if a doctor will graduate
in Summer ’18, candidates should be identified, ideally in Summer ’17—
though new candidates may be secured any time before the 30 Conrad slots
expire in the state);

• Know when to file a waiver application:

J-1 Waiver Applications should be filed as close to the beginning of the filing
window, usually in Sept. or Oct., as possible, though new filings can be made
up to the expiration of the 30 slots depending on the rules of each State
Program;

• Factor in time for an H-1B Visa:

H-1B status must be obtained before the foreign physician can begin work at
the facility – and note, a state medical license must be secured before the
H-1B visa status can be issued by USCIS.

• Allow enough time for State Dept. Review Board:

In order to make the July/August start date, employers will want to make sure
the J-1 Waiver application has progressed to the State Department Waiver
Review Division in the April to the early May timeframe.

Requirements for the Conrad Waiver program vary from state to state, for
example, some states place a priority on the visa for specific fields, such as family
physician or pediatrics. Believe it or not, some hospitals and healthcare facilities
aren’t familiar with using the Conrad Waivers or are intimidated by the process. If
you know an employer who needs help navigating the Conrad Waiver process, we
are happy to offer a complimentary consultation.

Employer Sponsored Petitions| Page 10

 Part 2: Employer Sponsored Petitions (cont.)
Other Employer Sponsored Visa Options
If the physician is not required to satisfy an HHR, and is licensed to practice
medicine in the U.S., there are several options for employer sponsored work
visas.

H-1B Visa
The H-1B visa is one of the most in-demand work visa in the United States.
While this visa type can be used by professionals in many industries, it is quite
popular for doctors. In order to get approved for this type of visa you need to
have an existing job offer for employment with a US employer. This can be a
hospital, university, clinic, a doctor’s office, or an assisted living community.

In addition, you must have

already completed your
medical degree from either a
US-based school, or an
acceptable school in a foreign
country. You will need to
apply for, and receive, your
medical license for the state
in which you plan to work.

Finally, you need to complete

either the United States
Medical Licensing
Examination (parts I, II and
III) or be eligible for the
limited exceptions to this
requirement (see below).

Employer Sponsored Petitions| Page 11

 Part 2: Employer Sponsored Petitions (cont.)
The H-1B quota is quickly filled each year, so you will need to plan far ahead
with the help of a skilled business immigration attorney like those at
FordMurray. Or, if possible, secure a position with an H-1B Cap Exempt
employer, such as a non-profit hospital with close ties to higher education
institutions. Download our H-1B Visa Guide for more information on H-1B
visas.

O-1 Visas
The O-1 visa can be a good option for many well-established doctors who are
looking to come to the US to practice. This visa, however, does require a
significant amount of documentation in order to qualify. To be approved for
this visa type you need to be able to demonstrate (through awards, publications,
or other evidence) extraordinary accomplishment in the medical field. In
addition, the position for which you are going to work must require someone of
well-above average skills and experience. Your abilities must be corroborated by
a consultation letters, which are essentially detailed letters of recommendation
from other respected experts in your specific field.

While it can take some time to gather together all the documentation and
evidence needed to apply for an O-1 Visa, the approval period is actually quite
fast when using premium processing. Once everything is submitted, O-1 visas
are typically approved or denied within a few weeks, which is faster than the
H-1B visa or most other options.

Employer Sponsored Petitions | Page 12

 Part 2: Employer Sponsored Petitions (cont.)
Additionally, physicians who qualify for the O-1 visa are exempted from the
USMLE examination requirement (note, however, that State licensing
requirement may still require USMLE passage).

TN Visa

If you are a doctor from Canada or Mexico, the TN visa may be the perfect
option for you. This visa was created as part of the North American Free Trade
Agreement. It is essential to note that this visa is for physicians who are going to
work in the US as either teaching or research doctors. While you are able to work
with patients directly, the total amount of time providing patient care should
make up less than 10% of your total duties

Self Sponsored Petitions | Page 13

 Part 3: Self Sponsored Work Visas and
Green Cards
U.S. immigration law provides two routes to permanent residence that do not
require sponsorship by a U.S. employer: the Extraordinary Ability petition and
the National Interest Waiver (NIW).

Extraordinary Ability Petition and National Interest Waiver

An individual can “self-petition” in either of these categories, meaning that they
can request a green card from the USCIS on their own behalf. Extraordinary
ability petitions and NIWs can be filed while holding a work visa – meaning you
can go through the self-petition process while working in the U.S. on an H-1B or
other employer sponsored visa. Although there is no job offer requirement for
these categories, an applicant still must demonstrate that they are “coming to the
United States to continue work in the area of expertise” in the case of the
Extraordinary Ability petition, and must be “well positioned” to advance their
proposed endeavor in the U.S. in the case of the National Interest Waiver.

While both pathways allow an

individual to self-petition, the criteria
for the Extraordinary Ability petition
and NIW are very different. A
physician’s specific background and
career are important factors in
determining which option is likely to
be successful.

Self Sponsored Petitions | Page 14

 Part 3: Self Sponsored Visas and Petitions (cont.)
The Extraordinary Ability category is for individuals who are publicly
recognized for his or her achievements. In order to prove extraordinary ability,
the applicant must be able to demonstrate national or international acclaim
through receipt of an internationally recognized award, such as a Nobel Prize or
Academy Award.
If that condition cannot be met, USCIS has said the burden of proof can be
satisfied with evidence from three of the following categories:
• Evidence of receipt of lesser nationally or internationally recognized prizes
or awards for excellence
• Evidence of your membership in associations in the field which demand
outstanding achievement of their members
• Evidence of published material about you in professional or major trade
publications or other major media
• Evidence that you have been asked to judge the work of others, either
individually or on a panel
• Evidence of your original scientific, scholarly, artistic, athletic, or business-
related contributions of major significance to the field
• Evidence of your authorship of scholarly articles in professional or major
trade publications or other major media
• Evidence that your work has been displayed at artistic exhibitions or
showcases
• Evidence of your performance of a leading or critical role in distinguished
organizations
• Evidence that you command a high salary or other significantly high
remuneration in relation to others in the field
• Evidence of your commercial successes in the performing arts

Self Sponsored Petitions | Page 15

 Part 3: Self Sponsored Visas and Petitions (cont.):

The National Interest Waiver is more open-ended regarding required evidence,

which lends itself to physicians who may be earlier in their careers. For an NIW, the
immigration service will be looking at three things:
• Whether or not your proposed work in the U.S. has “substantial merit” and
“national importance”. USCIS will consider many things for “substantial merit”,
including research that advances scientific knowledge in any given specialty. For
“national importance”, USCIS will look at the potential prospective impact of
your work.
• Whether or not you are “well positioned” to advance your proposed endeavor in
the U.S. This can include your education, skills and record of success in your field;
any progress toward your proposed endeavor like a business plan or funding for
your work; and the interest of others in the work that you propose to do.
• Whether or not it would be beneficial to the U.S. to waive the job offer and labor
certification requirements: i.e., you are planning to work in a medically
underserved area, or are engaged in important public health research.

Unlike other visa programs, such as

the H-1B, the criteria for EB visas are
somewhat discretionary. If you think
you might qualify for an extraordinary
ability or national interest waiver
petition, call us today for a
complimentary consultation.

We are happy to go over your

education, work experience, awards
and publications to help you identify
strengths in your case, and areas for
improvement.

Self Sponsored Petitions | Page 16

 Part 3: Self Sponsored Visas and Petitions (cont.):
E-2 Visa
The E-2 Visa is set up for investors who want to come to the United
States, but can be used for licensed doctors in some cases. If you are a
physician who is looking to invest heavily in a medical business in the US,
this may be a great option if you have a passport from an E treaty country.
Physicians can come to the US and start a healthcare practice or
healthcare related business to qualify for the E-2 Visa.
The requirements for this visa include an investment of at least
$100,000, a business that employs at least 2-3 people, and you must be the
majority owner of the business. You can hire employees from your home
country using an E Visa. For more information on the E Visa for
Investors, download our E Visa Guide.

Self Sponsored Petitions | Page 17

 Part 4: Planning Ahead for the Permanent
Residence
If you would like to plan for permanent residence in the United States, you will
either need to be sponsored by an individual or business, or self-petition for a
green card, as discussed in Part 4.

Business Sponsored Green Cards:

There are two primary ways for businesses to sponsor employees for permanent
resident status in the United States. The most common path to sponsoring an
employee is to initiate the Program Electronic Review Management (PERM)
process, under which the employer must advertise for the position and show no
qualified United States applicants can be identified for the position. Once PERM
certification is complete, the employer will file an I-140 petition, wherein they
must prove the foreign employee demonstrates the qualifications for the position
that was advertised during the PERM process.

The second avenue to

sponsorship is through an
EB-1 (extraordinary ability) or
EB-2 (National Interest
Waiver) petition, which
allows employers to bypass
PERM certification for
employees of extraordinary
ability, or who will work in
areas of “substantial intrinsic
merit” to the United States.

Planning for Permanent Residence | Page 18

 For these petitions, the foreign employee must possess an advanced degree and
have demonstratable exceptional ability in the sciences, arts or business, and/or
be able to prove the work they do is in the best interest of the United States.
While sponsoring an employee through the EB-1 and EB-2 process is a shorter
process, the qualifications are stringent for demonstrating extraordinary ability.
The PERM process can take up to a year. Sponsoring an employee for a green
card allows businesses to build on the experience of their valued team members.
Communication with your employer is vital if you hope to start down this path,
as the process should be started well before you approach the six year limit of
your H-1B visa.

Self-Petition Green Cards

While employers can sponsor employees for the EB-1 and EB-2 petitions, these
two visas also feature the ability to self-petition. EB-1 and EB-2 petitions do not
require a job or job offer in the U.S. for a successful petition, although an
applicant does need to demonstrate that they are coming to the U.S. to work in
their field of expertise. These cases are also for professionals who have a high
level of expertise in their fields. For more information on self-petition green
cards, download FordMurray’s Guide to Self-Petition Green Cards.

Planning for Permanent Residence | Page 19