U.S. Immigration Requirements:
Therapists and Allied Health Professionals
Written by Cindy Unkenholt, Hammond Law Firm
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erhaps now more than ever leading hospitals, research facilities and healthcare staffing agencies in the United States are looking beyond U.S. borders to help alleviate the shortage of healthcare workers. Previous efforts to recruit foreign healthcare workers were typically limited to nursing. However, as a result of shortages in other healthcare occupations, foreign recruitment in many allied healthcare occupations is on the rise. Canadian citizens are ideal candidates for recruitment to the United States, as they are eligible for TN nonimmigrant status which authorizes employment in a number of healthcare occupations. Additionally, regulatory changes effective in March 2005 make the recruitment of allied healthcare workers not eligible for TN status more attractive than ever before. Canadian citizens obtain TN status [created by the North American Free Trade Agreement ("NAFTA")] at the port-ofentry on the same day of admission to the United States, no prior petition or approval is required. Any citizen of Canada or Mexico with an offer of employment from a U.S. company or organization in one of the occupations specified by NAFTA who meets the eligibility standards for the occupation is eligible for TN status. There are currently sixty-three (63) occupations listed in NAFTA, twelve of which are healthcare related occupations: Registered Nurse, Recreational Therapist/Physiotherapist, Physical Therapist, Occupational Therapist, Medical Laboratory Technologist, Pharmacist, Psychologist, Physician, Nutritionist, Dietician, Dentist, and Veterinarian. Employers, recruiters and candidates should be aware, however, that certain healthcare workers must have their credentials evaluated and certified by an authorized organization before they can be admitted to work in the United States: Nurses, Physical Therapists, Occupational Therapists, Speech Language Pathologists, Medical Technologist/Clinical Laboratory Scientist, Physician Assistant, and Medical Technicians/Clinical Laboratory Technician. This law applies to healthcare workers who will enter the U.S. pursuant in a temporary visa status (such as TN or H-1b) as well as those seeking permanent resident status. Accordingly, Canadian citizens applying for TN status for employment in the United States as a Registered Nurse, Physical Therapist, Occupational Therapist or Medical Laboratory Technologist will require such certification before seeking admission. The certification encompasses a review of professional education and licensure as well as an assessment of English language skills. Additionally, for Registered Nurses only, certification requires
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successful passage of either the CGFNS examination or NCLEX examination. Canadian citizens educated in Canada (except Quebec) benefit from an exemption to the English language skills assessment if the language of instruction and textbooks were both in English. Currently only three organizations are approved to issue healthcare worker certificates. These are the National Board for Certification in Occupational Therapy, the Foreign Credentialing Commission on Physical Therapy and the Commission on Graduates of Foreign Nursing Schools. The applications for the healthcare worker certificate are available on the websites of each organization at www.nbcot.org; www.fccpt.org and www.cgfns.org and respectively. The National Board for Certification in Occupational Therapy (NBCOT) is authorized to issue certificates for Occupational Therapists; the Foreign Credentialing Commission on Physical Therapy (FCCPT) is authorized to issue certificates for Physical Therapists. Only the Commission on Graduates of Foreign Nursing Schools (CGFNS) is authorized to issue certificates (under the trademark name of a "Visa Screen") for all seven healthcare occupations requiring healthcare worker certificates for immigration purposes: nurses, physical therapists, occupational therapists, speech language pathologists, medical technologist/ clinical laboratory scientist, physician assistant, and medical technicians/ clinical laboratory technician. Overview of selected allied heath occupations commonly recruited from Canada and the respective nonimmigrant and immigrant options available:
Physical Therapists
Physical therapists help accident victims and individuals with disabling conditions to improve physical function and mobility. All states regulate the occupation of physical therapy and require graduation from a physical therapy educational program and a passing score on the national licensing examination, the National Physical Therapy Examination
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(NPTE). A Physical Therapist must also obtain a healthcare worker certificate from an approved organization before seeking admission to the United States. The two approved credentialing agencies for Physical Therapists are the Commission on Graduates of Foreign Nursing Schools (CGFNS), through its subdivision International Commission on Healthcare Professionals (ICHP) and the Foreign Credentialing Commission on Physical Therapy (FCCPT). A Canadian or Mexican citizen with an offer of employment as a Physical Therapist in the United States can qualify for TN status under the North American Free Trade Agreement (NAFTA) if he or she has a Baccalaureate or Licenciatura degree and/or a state/provincial license. A Physical Therapist must obtain a healthcare worker certificate from either FCCPT or CGFNS prior to seeking admission to the United States. A Physical Therapist can also qualify for H-1b status because the normal minimum requirement for the occupation is at least a Bachelor's Degree. The Administrative Appeals Unit has recognized the position of Physical Therapist as a specialty occupation. To be eligible for H-1b status, the individual must have the following: (1) an offer of employment in the United States as a Physical Therapist (2) the equivalent of at least a U.S. Bachelor's degree in physical therapy; (3) a license to practice in the state of intended employment; and (4) a healthcare certificate from CGFNS or FCCPT.
A Pharmacist can also qualify for H-1b status because the position requires at least a bachelor's degree. To be eligible for H-1b status, the individual must have the following: (1) an offer of employment in the United States as a Pharmacist or Pharmacist Intern (2) the equivalent of at least a U.S. Bachelor's degree in pharmacy; and (3) a license to practice in the state of intended employment, as applicable;
Medical Technologists
Medical technologists examine and analyze body fluids, tissues and cells. They are often referred to as Medical Laboratory Technologists, Clinical Laboratory Technologists or Clinical Laboratory Scientists. A Medical Technologist must also obtain a healthcare worker certificate from an approved organization before seeking admission to the United States. The approved credentialing agency for Medical Technologists is the Commission on Graduates of Foreign Nursing Schools (CGFNS), through its subdivision International Commission on Healthcare Professionals (ICHP). A Canadian or Mexican citizen with an offer of employment as a Medical Technologist in the United States can qualify for TN status if he or she has been awarded a Baccalaureate or Licenciatura degree or, in the alternative to such a degree, a post-secondary diploma and three years of relevant experience. Additionally, a Medical Technologist must obtain a healthcare worker certificate from CGFNS before seeking admission in TN status. Under NAFTA, a Medical Laboratory Technologist is restricted to working in a laboratory and performing "chemical, biological, hematological, immunologic, microscopic or bacteriological tests and analysis for diagnosis, treatment or prevention of diseases." A Medical Technologist, whether or not working in a medical laboratory, can also qualify for H-1b status. The Administrative Appeals Unit has recognized the profession of Medical Technology as a specialty occupation for H-1b purposes. To be eligible for H-1b status, the individual must have the following: (1) an offer of employment in the United States as a Medical Technologist; (2) the equivalent of at least a Bachelor's degree in medical technology or a closely related field of study; (3) a license to practice medical technology if the state requires a license; and (4) a healthcare worker certificate from CGFNS. It is important to note that the position of Medical Technologist is distinctly different from that of Medical Technician. A Medical Technician is a non-professional occupation that does not require a bachelor's degree (and is therefore not eligible for H-1b status) and is not specified by NAFTA (and therefore not eligible for TN status). However, note that a Medical Technician (also called a Clinical Laboratory Technician) does require a healthcare worker certificate from CGFNS.
Pharmacists
Pharmacists dispense drugs prescribed by physicians and provide patients with information about medication. Pharmacists must be licensed by the state board of pharmacy in the state of employment. Licensing requirements vary among states but require, at a minimum, the following: graduation from an accredited college of pharmacy, a passing score on the state licensing examination known as the North American Pharmacist Licensure Examination (NAPLEX) and completion of an internship under the supervision of a licensed pharmacist. The internship generally ranges from 500 to 1500 hours, during which time the individual is authorized by the state to work as a "Pharmacist Intern". A foreign national who did not obtain his or her degree from a U.S. college or university must take the Foreign Pharmacy Graduate Equivalency Exam (FPGEE) and English proficiency examinations (TOEFL and TSE) to be eligible to begin an internship and take the pharmacist licensure examination (NAPLEX). A Pharmacist does not need to obtain a healthcare worker certificate from an authorized organization prior to seeking admission to the United States. The Illegal Immigration Reform and Immigrant Responsibility Act of 1996 (IIRIRA) and the CIS Regulations implementing the Act did not include Pharmacists as one of the healthcare occupations requiring a healthcare worker certificate. A Canadian or Mexican citizen with an offer of employment as a Pharmacist in the United States can qualify for TN status under the North American Free Trade Agreement (NAFTA) if he or she has a Baccalaureate or Licenciatura degree and/or a state license or provincial license.
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Occupational Therapists
Occupational therapists help patients with physically, mentally, emotionally or other disabling conditions perform physical tasks. A Bachelor's degree is the minimum requirement to work as an occupational therapist and all states
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require an Occupational Therapist to be licensed in the state of employment. While the requirements for licensure vary slightly among the states, all require graduation from an accredited educational program and a passing score on the national licensing examination, the certification examination for Occupation Therapist Registered OTR™. An occupational therapist must obtain a healthcare worker certificate prior to seeking admission to the United States. The only two organizations currently authorized to issue healthcare worker certificates for Occupational Therapists are the Commission on Graduates of Foreign Nursing Schools (CGFNS) through its subdivision International Commission on Healthcare Professionals (ICHP) and the National Board of Occupational Therapy (NBCOT). A Canadian or Mexican citizen with an offer of employment as an Occupational Therapist can qualify for TN status if he or she has been awarded a Baccalaureate or Licenciatura degree and/or has obtained a state or provincial license. Additionally, an Occupational Therapist must obtain a healthcare worker certificate from CGFNS before seeking admission in TN status. An Occupational Therapist can also qualify for H-1b status since the profession requires at least a Bachelor's degree. To be eligible for H-1b status, an individual must have (1) an offer of employment in the United States as an Occupational Therapist; (2) the equivalent of a U.S. Bachelor's degree in occupational therapy or a closely related field of study; (3) a license to practice in the state of intended employment; and (4) a healthcare worker certificate from CGFNS or NBCOT.
under the North American Free Trade Agreement (NAFTA). Speech Language Pathologists and Audiologists can, however, qualify for H-1b status since the normal requirement for the occupation (master's degree) exceeds the H-1b minimum requirement of a bachelor's degree. To qualify for H-1b status, an individual must have (1) an offer of employment in the United States as a Speech Language Pathologist or Audiologist; (2) a bachelor's degree (or master's degree) in speech language pathology or audiology; (3) a license to practice the profession in the state of intended employment; and (4) a healthcare worker certificate from CGFNS.
Respiratory Therapists, Ultrasound Technologists & Radiology Technologists
A Respiratory Therapist evaluates, treats, and cares for patients with breathing or other cardiopulmonary disorders. Radiology Technologists and Radiology Technicians take x rays and administer nonradioactive materials into patients' bloodstreams for diagnostic purposes. Some specialize in diagnostic imaging technologies, such as computerized tomography (CT) and magnetic resonance imaging (MRI). Ultrasound Technologists, also often referred to as Diagnostic Medical Sonographers, perform ultrasound examinations to produce pictures of patients' internal organs or of a pregnant woman's unborn baby. Generally, Respiratory Therapists, Ultrasound Technologists, and Radiology Technologists cannot be admitted to the United States in TN status as these occupations are not specifically listed by NAFTA. Because of the vast difference in adjudications at various ports-of-entry, it is possible that a Canadian citizens working in any of these positions could be admitted in TN status (under a broader occupational category). However, such an application for admission would be difficult and would not likely be approved on any consistent basis. Additionally, even if initially admitted, future grants of TN status or extensions would likely be denied. Respiratory therapists, ultrasound technologists, and radiology technologists also do not qualify for H1b status since these positions do not require a bachelor's degree. However, Respiratory Therapists, Ultrasound Technologists, or Radiology Technologists may be admitted to the United States as Lawful Permanent Residents through the 'labor certification' process. Labor certification is the first step in obtaining an employer sponsored green card. (Unless the occupation has been designated by the Department of Labor on Schedule A as a shortage occupation and is therefore exempt from this requirement. Physical Therapists and professional Nurses are the only healthcare occupations listed on Schedule A.) Prior to March 28, 2005, the labor certification process frequently took three years or longer to be completed. This extensive processing time made it impractical to recruit foreign allied heath care workers who were not eligible for the TN status. However, with the implementation of a new labor certification program by the U.S. Department of Labor ("PERM"), recruitment of these occupations is now feasible. The cornerstone of the new PERM system remains consistent with the previous program, a labor market test to determine
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Speech Language Pathologists or Audiologists
Speech Language Pathologists work with patients who have speech problems which may have resulted from various causes including hearing loss, brain injury, cerebral palsy, stroke, cleft palate or emotional problems. Audiologists work with patients who have hearing problems which may have resulted from birth trauma, genetic disorders, exposure to loud noise or aging. According to the Occupational Outlook Handbook, the normal requirement for Speech Language Pathologists and Audiologists is a master's degree in speech language pathology or audiology. Almost all states regulate speech language pathology and audiology. The requirements for state licensure typically involve a master's degree or equivalent in the relevant field of study, a passing score on the national licensing examination and several months of clinical experience. Speech Language Pathologists and Audiologists must obtain a healthcare worker prior to seeking admission to the United States. Currently, the only approved credentialing agency for Speech Language Pathologists and Audiologists is the Commission on Graduates of Foreign Nursing Schools (CGFNS), through its subdivision International Commission on Healthcare Professionals (ICHP). A Canadian or Mexican citizen with an offer of employment as a Speech Lanaguage Pathologist or Audiologist in the United States is not eligible for TN status. Speech language pathologist and audiologist are not occupations specified
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the availability of qualified U.S. workers. However, of particular note with respect to the recruitment of allied healthcare workers, processing of PERM applications is now automated and processing times are approximately 45-60 days. The practical implication is that assuming there are no backlogs for immigrant visas ("retrogression") the recruitment of allied healthcare workers who are not eligible for TN or H-1b status is realistic and similar in timing to the recruitment of a Registered Nurse who is not a Canadian citizen. [When the demand for immigrant visas exceeds the annual quota, "retrogression" can delay issuance of the immigrant visa and therefore employment authorization in the United States.] Those who have not explored recruiting foreign allied healthcare workers in several years because of the roadblocks imposed by the U.S. immigration system should reconsider in light of recent changes.
See National Association of Boards of Pharmacy website at www.nabp.net. 7 Some states recognize the position of "pharmacy technician" which requires only a high school diploma and therefore does not qualify for H-1b status. 8 See 8 C.F.R. 214.2(h) (4) (v) for the ways to fulfill the license requirement. 9 See IN RE: X, 13 I&N Dec. 581(D.A.C. 1970). 10 See American Medical Technologists website at www.amt1.com. 11 See 8 C.F.R. 212.15(e). 12 See U.S. Department of Labor, Occupational Outlook Handbook, available at www.bls.gov. 13 See the National Board for Certification in Occupational Therapy, Inc. website at www.nbcot.org. 14 See 8 C.F.R. 212.15(e). 15 H-1b status is not limited to a specific citizenship as TN status under NAFTA is limited to Canadian and Mexican citizenship. 16 See 8 C.F.R. 214.2(h) (4) (v) for the ways to fulfill the license requirement. 17 See U.S. Department of Labor, Occupational Outlook Handbook, available online at www.bls.gov.
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See the Federation of State Boards of Physical Therapy website at www.fsbpt.org. 2 IN RE: X, 14 Immig. Rptr. B2-65 (January 26, 1995). 3 See 8 C.F.R. 214.2(h) (4) (v) for the ways to fulfill the license requirement. 4 See the Commission on Graduates of Foreign Nursing Students website at www.cgfns.org and the Foreign Credentialing Commission on Physical Therapy website at www.fccpt.org. 5 See U.S. Department of Labor, Occupational Outlook Handbook, available online at www.bls.gov.
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Cindy Unkenholt is an attorney with Hammond Law Group, a Cincinnati based law firm with offices in San Francisco and Toronto, Canada. The firm practices exclusively in the area of business immigration law. The firm handles literally 1000’s of heath care cases per year for hospitals, recruiters, staffing agencies, healthcare facilities and individuals. The firm publishes a well-recognized electronic newsletter, the Medical Monthly Monitor. Firm members in the health care practice group have published articles in numerous national and international publications and often speak at seminars and trade shows.
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