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Explore ReferentDate: [Date]
To: U.S. Citizenship and Immigration Services (USCIS)
Re: I-601 Waiver Support – Medical Hardship Statement for [Name of Qualifying Relative]
Applicant: [Applicant Full Name] | A-Number (if any): [A-Number]
Qualifying Relative: [Full Name] | Relationship: [Spouse/Parent]
To Whom It May Concern,
1.1 Full Name: [Your Full Name]
1.2 Date of Birth: [DOB]
1.3 Address: [Address]
1.4 Phone/Email: [Contact]
1.5 Relationship to Applicant: [Spouse/Parent]
1.6 Household Members/Dependents: [Names + ages]
2.1 I am writing to explain the medical hardship I would face if the I-601 waiver for [Applicant Name] is denied.
2.2 The applicant’s presence is essential to my health, daily functioning, and stability.
3.1 Diagnoses/Conditions:
[Condition #1] – Diagnosed: [Date/Year] – Treating provider: [Doctor/Clinic]
[Condition #2] – Diagnosed: [Date/Year] – Treating provider: [Doctor/Clinic]
[Condition #1] – Diagnosed: [Date/Year] – Treating provider: [Doctor/Clinic]
[Condition #2] – Diagnosed: [Date/Year] – Treating provider: [Doctor/Clinic]
3.2 Current Symptoms and Limitations (Plain Language):
[Describe how the condition affects daily life—mobility, pain, fatigue, breathing, concentration, etc.]
3.3 Treatment Plan:
Medications: [List or “see attached”]
Appointments: [Frequency + specialists]
Procedures/Therapy: [Physical therapy, surgery plan, etc.]
Medications: [List or “see attached”]
Appointments: [Frequency + specialists]
Procedures/Therapy: [Physical therapy, surgery plan, etc.]
3.4 Medical Access and Insurance:
Insurance coverage: [Plan/Status]
Primary providers/hospital: [Names]
Estimated monthly out-of-pocket costs (if known): $[Amount]
Insurance coverage: [Plan/Status]
Primary providers/hospital: [Names]
Estimated monthly out-of-pocket costs (if known): $[Amount]
4.1 Caregiving and Daily Support. [Applicant Name] helps me with:
[Transportation to appointments]
[Medication management]
[Household tasks I cannot do safely]
[Childcare or dependent care]
[Monitoring symptoms/emergencies]
[Transportation to appointments]
[Medication management]
[Household tasks I cannot do safely]
[Childcare or dependent care]
[Monitoring symptoms/emergencies]
4.2 Health Impact of Separation. If we are separated, I expect:
Worsening symptoms due to stress and reduced support
Missed appointments or limited ability to travel to care
Increased financial strain affecting treatment adherence
Reduced ability to work and maintain insurance coverage
Worsening symptoms due to stress and reduced support
Missed appointments or limited ability to travel to care
Increased financial strain affecting treatment adherence
Reduced ability to work and maintain insurance coverage
4.3 Safety Concerns (If Applicable): [Falls, seizures, mobility limits, emergency response needs.]
5.1 If I relocate to [Country], I would face hardship due to:
Limited access to specialists/medications I currently rely on
Higher costs or lack of insurance coverage
Language or cultural barriers in healthcare settings
Safety and stability concerns that would affect my health
Limited access to specialists/medications I currently rely on
Higher costs or lack of insurance coverage
Language or cultural barriers in healthcare settings
Safety and stability concerns that would affect my health
5.2 Continuity of Care. My current providers have established a treatment plan that would be difficult to replicate quickly.
6.1 Employment and Income: [Your job + impact].
6.2 Care Costs: Without [Applicant Name], I would likely need paid help for: [Transportation, caregiving, childcare]. Estimated cost: $[Amount]/month.
6.3 Housing and Family Stability: [Explain briefly].
7.1 I have experienced: ☐ anxiety ☐ depression ☐ panic symptoms ☐ other: [Describe] related to this situation.
7.2 Treatment/support: [Therapy, counseling, medication, support group].
8.1 I am including copies of supporting documents such as:
Doctor letters and diagnosis summaries
Medical records (summary pages)
Prescription lists
Appointment schedules
Insurance documents and medical bills (summary)
Proof of caregiving responsibilities (statements, schedules)
Other: [List]
Doctor letters and diagnosis summaries
Medical records (summary pages)
Prescription lists
Appointment schedules
Insurance documents and medical bills (summary)
Proof of caregiving responsibilities (statements, schedules)
Other: [List]
9.1 I respectfully request that USCIS consider the medical hardship described above and grant the waiver for [Applicant Name].
9.2 Everything in this letter is true and correct to the best of my knowledge.
Sincerely,
[Your Full Name]
Signature: ___________________________
Date: [Date]
Witness Name: [Name]
Date: [Date]
Signature: ___________________________
State of [State]
County of [County]
On [Date], before me, [Notary Name], personally appeared [Your Full Name], known to me (or satisfactorily proven) to be the person whose name is subscribed to this letter, and acknowledged that they executed it for the purposes stated.
Notary Public Signature: _______________________
My Commission Expires: _______________________
Notary Seal (if applicable): ___________________
Each template already follows legal structure and best practices.
The agreement is automatically filled and adapted to your inputs.
Check the generated document, make edits if needed, and download a ready-to-use agreement.
Click below for detailed info on the template.
For quick answers, scroll below to see the FAQ.
Frequently asked
A Medical Hardship Letter is a personal statement used as part of an I-601 waiver packet to explain how a qualifying relative would suffer hardship due to medical conditions if the waiver is not granted. It typically describes diagnosis, treatment needs, access to care, daily functioning, and why separation or relocation would be especially difficult.
Often the qualifying relative (or the petitioner/spouse if they are the one experiencing the hardship) writes the letter. In some cases, caregivers or family members provide supporting statements. The letter should be factual, personal, and consistent with medical records.
Common supporting items include: doctor letters, medical records (summary pages), prescriptions, treatment plans, insurance documents, proof of ongoing appointments, and statements showing caregiving responsibilities. This template includes a checklist-style section you can adapt.
Share enough to show the seriousness and practical impact, but avoid unnecessary private details. Use plain language and explain how symptoms affect daily life, work, and family responsibilities.
If relevant and documented, yes. Mental health impacts can be important in hardship analysis. This template includes an optional section to describe counseling, diagnoses, and treatment, without requiring you to share sensitive details.
AI Lawyer is an AI-powered assistant that helps you create and customize legal and business document templates online. It guides you through key sections, suggests wording, and explains complex concepts in simple language. AI Lawyer does not replace a licensed attorney or provide legal advice, but helps you prepare better documents faster and more confidently.
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