Medical Hardship Letter (I-601) Template

Date: [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. About Me and My Household

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. Purpose of This Letter

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. Medical Conditions and Treatment

3.1 Diagnoses/Conditions:

• [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.]

3.4 Medical Access and Insurance:

• Insurance coverage: [Plan/Status]

• Primary providers/hospital: [Names]

• Estimated monthly out-of-pocket costs (if known): $[Amount]

4. Why Separation Would Cause Extreme Hardship

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]

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

4.3 Safety Concerns (If Applicable): [Falls, seizures, mobility limits, emergency response needs.]

5. Why Relocation Would Also Be a Hardship (If Applicable)

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

5.2 Continuity of Care. My current providers have established a treatment plan that would be difficult to replicate quickly.

6. Financial and Practical Impacts

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. Mental Health (Optional)

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. Supporting Evidence (Attach as Available)

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]

9. Closing Statement

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]

Signatures

Signature: ___________________________

Date: [Date]

Witnesses (If Required)

Witness Name: [Name]

Date: [Date]

Signature: ___________________________

Notary / Notarization (Optional)

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): ___________________