Have a question about medical clearances? We’ve compiled a list of Frequently Asked Questions.
Foreign Service Officers are required to serve much of their career overseas. In the spirit of that requirement prolonged continuous service domestically of greater than six years requires permission from Human Resources. Pertinent sections of the Department of State Human Resources SOP A-04 state:
The Foreign Service Act of 1980, as amended, 22 U.S.C.§3901 et seq., requires all Foreign Service employees to serve a substantial portion of their careers overseas and limits the number of years Foreign Service employees can spend in continuous domestic assignments. The purpose of this SOP is to establish procedures and criteria for considering requests for waivers of the requirement for overseas service, (1) after six years of continuous domestic assignments, and (2) after eight years of continuous domestic assignments.
The Six-Year Rule. The Six-Year Rule is set forth in 3 FAH-1 H-2423.2, which states that continuous domestic assignments may not exceed six years without a waiver from the Director General. The Director General has delegated the authority to grant such a waiver to the Director of HR/CDA (Bureau of Human Resources, Office of Career Development and Assignments) by memorandum dated August 8, 2005.
The Eight-Year Rule. The Eight-Year Rule is set forth in the Foreign Service Act at §504, 22U.S.C.§3984, which states, “A member of the Service may not be assigned to duty within the United States for any period of continuous service exceeding eight years unless the Secretary approves an extension of such period for that member because of special circumstances.”
Where a particular physical or mental health condition, extraordinary stress, or similar circumstances a represented as the justification for a 6/8 waiver, MED or an outside medical professional must confirm the basis for the A-4.4A-04 revised 01/2018 request. The Committee reserves the right to seek MED’s opinion when it deems such opinion is necessary for proper adjudication of the request (see Section below), consistent with applicable privacy laws and policies. The point of contact in MED is the Director of Medical Clearances, who will relay the request to the appropriate office or person in MED and return a formal recommendation to the CDO or Committee, as appropriate.
Confidential Medical Information. Many waiver requests are based on confidential medical or mental health information regarding the requesting employee and/or members of the employee’s family. Such information should be provided directly to the Director of Medical Clearances in the Office of Medical Services, not to the CDO. The waiver justification need only provide enough information from the employee and/or MED to demonstrate a strong basis for the request to enable the Committee to make are commendation. MED or Employee Consultation Services (ECS) statement of support or non-support, as appropriate, should be included in all waivers based on limited medical clearances or on compassionate grounds.
Employees subject to the six or eight-year rule must work with their CDOs if they wish to request a waiver of the rule. Such requests should be submitted no earlier than May prior to the new bidding cycle and no later than 30 days prior to the bid due date. Employees requesting a waiver should follow the instructions in Human Resources SOP A-04. A waiver request should be sent to an employee’s CDO, who will forward it to the Five/Eight Committee.
Requests for a 6/8 waiver where neither the employee nor a family member has any special physical or mental health condition that would require the Bureau of Medical Services’ (MED’s) expertise may be considered by the Committee without MED input. Examples include, but are not limited to, the need to spend time with otherwise healthy children to assist their readjustment to new living circumstances; to complete an adoption; or to assist in the career or personal needs of a non-tandem spouse.
Where a particular physical or mental health condition, or extraordinary stress are the basis or for the request. The Committee reserves the right to seek MED’s opinion when it deems such opinion is necessary for proper adjudication of the request, consistent with the Health Insurance Portability and Accountability Act (HIPAA) and implementing regulations at 45 C.F.R. Parts 160 and 164. The point of contact in MED is the Chief of Domestic Programs (MEDDP@state.gov), who will relay the request to the appropriate office or person in MED and return a formal recommendation to the CDO or Committee, as appropriate.
16 FAM 211.2 Clearance Classifications
(CT: MED-43; 02-25-2020)
(Uniform State/USAID/U.S. and Foreign Commercial Service/Foreign Agricultural Service/Animal and Plant Health Inspection Service/USAGM)
(Applies to all U.S. Government Employees and Eligible Family Members Participating in the Department of State Medical Program)
- Worldwide Available (Class 1): Issued to applicants, employees and eligible family members who have no identifiable medical conditions that would limit assignment abroad.
- Post-Specific (Class 2): Issued to an individual with a medical condition that would pose a significant risk to the health or safety of the individual or others if the individual were assigned to work at one or more posts abroad. The [Bureau] of Medical Services (MED) determines approval for assignment to a specific post based on the criteria above. See Post Specific (Class 2) Clearance for details.
- Domestic Only (Class 5): Issued to all who have a medical condition which is incapacitating, or for which specialized medical care is best obtained in the United States. Employees or eligible family members with a Class 5 medical clearance may not be assigned outside the United States.
- Temporary Travel (Class 6): Issued only to an eligible family member who is not medically cleared to reside at the employee’s assigned post but is authorized to visit that post for a period of time not to exceed 120 days per calendar year.
- Pending (Class 7): Issued to individuals awaiting completion of the evaluation of a medical condition within 90 days. Class 7 is not valid for travel to an assignment abroad. If the examination/evaluation is not completed within 90 days, the individual will be issued a Class 8 clearance and will not be eligible for the Medical Program abroad.
- Incomplete/Cancellation (Class 8): Issued to an individual whose pre-employment medical evaluation is incomplete and the application has been inactive for more than 90 days. Class 8 clearances will also be issued to an employee or eligible family member who is in pending status (Class 7) and who has not completed the evaluation within the allotted 90 days.
- Separation (Class 9): Issued to employees and eligible family members following separation from State’s Medical Program. This includes eligible family members who have reached age 21, or persons leaving the program through legal separation or divorce. Although qualified students who travel on educational travel orders are eligible for care abroad under the Medical Program up to their 23rd birthday (16 FAM122.2, subparagraph a(2)), their separation examination must be completed within 90 days of their 21st birthday (16 FAM 122.2, subparagraph a(1)).
- Deceased (Class 10): Issued to employees or eligible family members at notification of death.
The Department of State has identified certain posts as Employee Self-Certification and Ability to Perform in Emergencies (ESCAPE) posts. ESCAPE posts comprise a subset of Special Incentive Posts (SIP). All direct hire employees, Locally Employed Staff, contractors, and Eligible Family Members who will be posted to a designated ESCAPE posts for 30 or more consecutive days are required to obtain a more comprehensive medical clearance than other posts. ESCAPE posts have limited medical capabilities and personal security risks. All individuals going to these posts must meet strict medical standards.
Current ESCAPE Posts Include:
- Afghanistan, Erbil, Iraq, Libya, Peshawar, Somalia, Syria, and Yemen
Medical Clearance Process for ESCAPE Posts
The process for completing an ESCAPE post clearance varies by your employment status and where you are going. Please return to “Start Here” to click on the steps to a medical clearance that best fits your status and overseas assignment.
How Long is an ESCAPE Post Clearance Valid?
A medical clearance to an ESCAPE post expires at:
- 1 year after arrival at post for all individuals deploying to an ESCAPE post.
- 1 year after issuance of a medical clearance of all individuals who extend at an ESCAPE post.
- 2 years after an issuance of a medical clearance to all individuals who perform TDY travel of 30 or more consecutive days to an ESCAPE post.
Tips to Employees Completing ESCAPE Post Forms
- Indicating the ESCAPE post(s) of assignment is REQUIRED. You should list any posts you may travel to. If you are TDY indicate if you are CONUS or overseas based, all possible ESCAPE posts you may travel to, and the estimated duration of your TDY stay. If you shuttle between two ESCAPE posts, especially Baghdad and Erbil, please indicate both.
- All blanks need to be filled in. Please be sure that the name, DOB, and email address are all printed clearly. The name of the examinee (employee, contractor, LES or EFM) and DOB must also appear at the top of each page 2, 3, and 4.
- The employee, contractor, LE Staff, or EFM must provide a full explanation of all answers checked “Yes” on page 2. Provide explanations in section IIA on page 2 or on a separate sheet of paper.
- On the , the Employee, Contractor, LE Staff, or EFM must sign and date the bottom of page 2. Unsigned forms will not be accepted by Medical Records.
- Contract employees should refer to their Contracting Office Representative (COR) to determine if they are participants in ICASS for medical care. Once employee obtains verification of ICASS medical program participation, submit the signed:
- 3308: DOD ICASS Verification Form,
- 3308.5: Institutional Contractor ICASS Verification Form,
- , and
- co-signed by the examining provider.
Tips to Medical Providers Completing ESCAPE Post Forms
- The healthcare provider should review all yes answers on page 2 of the and provide relevant comments.
- The healthcare provider must also review all current medications, dosages, and frequency of use. Allergies must also be reviewed.
- All items listed in the physical exam section on page 3 must be completed by the medical provider (examiner).
- All chronic medical conditions must be listed on page 4 in assessment or problem list section. Each diagnosis must have a statement clarifying prognosis, stability, follow-up plan, and if that follow-up must be done by a specialist. An additional sheet of paper may be used if more space is needed. Providers are also encouraged to submit supporting medical reports, labs, and consults for each chronic condition. All foreign reports must be in English or translated into English.
- The healthcare provider must print or stamp their name, as well as sign and date page 4. Unsigned forms will not be accepted by Medical Records.
- All optional tests are optional, unless clinically indicated, and not required for an ESCAPE post clearance.
- Medical providers (examiners) should check the box if the individual is fit or is not fit to work in the conditions stated on page 1 of the . Health care providers SHOULD NOT approve anyone they feel is not able to perform the functions outlined. Assure that the designated ESCAPE post(s) is (are) identified on page 1 of the DS-6570.
All personnel and their EFMs who have been issued a medical clearance in the past must update their clearance prior to departure for a new overseas assignment. Because everyone is “medically cleared” to be in the United States, individuals whose next tour is a domestic assignment do not require a medical clearance unless they will be doing TDY travel of 30 or more consecutive days during their domestic tour.
The medical clearance process is designed to identify medical, mental health, or educational issues before departing for an overseas assignment. All persons posted overseas or on TDY travel for 30 or more consecutive days must have a valid medical clearance before they can access a post’s Health Unit and other Medical Program benefits including assistance with a medical evacuation or hospitalization. While a medical clearance is not required for TDY travel of less than 30 days, persons with health concerns should avoid travel to localities where medical care is inadequate to meet their needs even if that travel is only for a few days.
People who have no significant health concerns can be posted anywhere in the world and are given a Worldwide Available (Class 1) clearance. However, for some individuals with on-going medical, mental health or educational issues adequate medical resources may not be available in all countries. Medical Clearances matches that individual’s medical needs with posts capable of providing the specific medical or educational services they need. Medical Clearances will not “clear” an individual to go to a post that does not have adequate resources for that person. If a person is not Worldwide Available, MED Clearances will issue a Post Specific (Class 2) with a list of approved countries or a Domestic Only (Class 5) medical clearance for those whose care is best only with a domestic assignment.
When to Start the In-Service Clearance Process
An FSO or Eligible Family Member (EFM) may start updating their medical clearance one year prior to departing from their current post or domestic assignment. Other agency employees, contractors or their family members may begin one year prior to their overseas assignment or training.
For children with special educational needs, starting early is important. Schools are often closed during American summer months, so the process needs to start well before the end of the school year for children with educational issues.
Who Should Use a Medical Clearance Update Form?
A is the preferred method of renewing a medical clearance. This brief, two-page document requires does not require a physical exam. The following in-service employees, contractors and EFMs are required to update their medical clearance and can use the MCU form:
- moving from one overseas assignment to another overseas assignment
- moving from a domestic assignment to a new overseas assignment
- on TDY overseas for more than 30 consecutive days
- extending REA/WAE status
- taking language or extended CONUS training… the clearance is for the assigned post after language training
- linked assignment for both current and linked assignment.
- extending at an ESCAPE post, the MCU (plus co-signed by the examining provider) can be used ONLY if the (MCU) is done at an ESCAPE post Health Unit
- any individual who has had a new medical condition that may affect their medical clearance at the posting they are currently at or will be posted to
- first time medical clearance
- moving agencies
- separation exam
- first time REA/WAE exam
- deploying to an ESCAPE post (plus co-signed by the examining provider)
- extending at an ESCAPE post (plus co-signed by the examining provider) and the individual is not at an ESCAPE post Health Unit
The Inservice Medical Clearance Process
The process for completing the in-service clearance varies by employment status and where you are going. Please return to “Start Here” to click on the steps to a medical clearance that best fits your status and overseas assignment.
Tips for Your In-Service Medical Clearance Update
- Take charge! Ask questions! Get involved! It is your clearance. Failure to have all family members’ medical clearances completed will delay the issuing of travel orders for individuals departing Washington D.C.
- List your prescription medications, hospitalizations, and medical conditions since your last clearance.
- Individuals who currently have a Post Specific (Class 2) medical clearance or have a new significant medical, mental health or educational issue will need to supply supporting documentation of their condition and treatment plan. Start collecting this information early.
- Clearly print the person’s name on each page submitted to Medical Records.
- Provide a current phone number and valid mailing address that can be used even if you are between posts on home leave or personal travel. Medical Clearance Notices will be sent to your e-mail address you place on your form. Please print your email legibly.
- Please check the signature area. A missing signature will delay the medical clearance review process.
- Do not travel to your next overseas assignment without a valid medical clearance
The medical clearance process is designed to identify on-going medical, mental health, or special educational issues for which adequate resources may not be available at a specific post. All persons must undergo a full physical exam for their first medical clearance. In addition, individuals changing sponsoring agencies, deploying to an ESCAPE post, separating from the Federal Government, or becoming a REA/WAE employee are treated as “new employees” and will need to complete a full pre-employment or pre-assignment exam.
Worldwide Availability Requirement for Foreign Service Officer Candidates, Fellows, and some First-Time Limited Non-Career Appointees
Foreign Service Officers Candidates, Foreign Service Fellows, and some first-time Limited Non-Career Appointees under the 5 Foreign Services Agencies must be able to serve at any post in the world for their first tour. These individuals must receive a Worldwide Available (Class 1 Clearance) based on their pre-employment medical exam.
Employees of other Government agencies, contractors, and all Eligible Family Members (EFMs) do not need to meet this worldwide availability requirement on their first overseas assignment.
Pre-Employment or Pre-Assignment Medical Clearance Process for ESCAPE Posts
The process for completing a Pre-employment or Pre-assignment medical clearance varies by on t employment status and where you are going. Please return to “Start Here” to click on the steps to a medical clearance that best fits your status and overseas assignment.
Other Medical Information for a Pre-employment or Pre-assignment Medical Clearance
Medical, Mental Health or Educational reports do not need to be submitted with your initial medical clearance forms but be aware that Medical Clearances may require reports from providers, medical facilities, or schools for anyone with significant past medical, mental health, or special educational needs.
ESCAPE Posts: Afghanistan, Iraq, Yemen, Somalia, Libya, Syria, and Peshawar
Individuals assigned to any of these ESCAPE posts, including TDY travel of 30 or more consecutive days, must meet more rigid standards, and undergo further medical vetting than addressed in this document. Please read and follow the instructions in Medical Clearance Guidance for Deploying to ESCAPE Posts.
Where to Perform a Pre-Employment or Pre-Assignment Medical Clearance Exam
- The medical clearance exam may be completed for you and your family members by a licensed medical provider of your choice.
- Many Embassy or Consulate Health Units will complete a pre-employment or pre-assignment medical clearance. This is not guaranteed. Many Health Units do not have a provider, resources, or time to complete a medical clearance.
Medical Clearance related medical expenses can be reimbursed by receiving a DS-3069 payment authorization form from your human resources and submitting your invoices and “Explanation of Benefits” to Medical Claims at MEDClaims@state.gov.
Contractors and DOD Civilians should contact their sponsor’s human resources regarding payment.
Tips for Submitting Your Medical Clearance Application
- Failure to have all family members’ medical clearance in order may delay your travel orders.
- Ideally type the form.
- Ensure the patient’s name and date of birth is at the top of each page of the exam form.
- The individual, parent or guardian should complete the first two pages of each form. Page 2 must be signed and dated. The examiner/provider should complete the physical exam, lab, and assessment/plan portion of the exam. The examiner must sign page 4. MED requires copies of any lab, radiology reports and EKG tracing when indicated on the physical form.
- Provide a personal, legible e-mail address good for the next 90 days.
- All forms, labs and reports should be in English or with an English translation.
- EFMs, age 18 and over, must provide their own email address for privacy reasons
- After a Medical Clearance is issued, any required follow-up care for any medical condition is the patient’s responsibility. Patients can arrange appointments on personal travel, during R&R, home leave or other government funded travel when services are not available at the post of assignment.
Guidance for Post Specific (Class 2) or Domestic Only (Class 5) Employees, Contractors, and Eligible Family Members
The medical clearance process is designed to identify medical, mental health, or educational issues before departing for an overseas assignment. For some individuals with on-going medical, mental health or educational issues adequate medical resources may not be available in all countries. Medical Clearances matches that individual’s medical needs with posts capable of providing the specific medical or educational services they need. Medical Clearances will not “clear” an individual to go to a post that does not have adequate resources for that person.
MED Clearances will issue a Post Specific (Class 2) clearance only to posts capable of meeting that individual’s needs. For example, if an individual needs to routinely see a neurologist or an English-speaking speech therapist or attend a school capable of supporting a dyslexic child there are posts he or she can be assigned to, but many other posts that do not have neurology, speech therapy and appropriate schools.
MED Clearances will issue a Domestic Assignment Only (Class 5) clearance for medical, mental health or educational issues where appropriate care is best obtained in the United States.
When to Start the Medical Clearance Process for an Individual with a Post Specific (Class 2) or Domestic Assignment Only (Class 5) Clearance
If you or your EFM has a Post Specific (Class 2) clearance, we recommend you act early. Obtaining reports from specialists, hospitals, therapists, and schools is time consuming. You may begin submitting documents up to one year prior to departing your current post or domestic assignment.
Medical Clearances must see reports from your specialists regarding the status of your health or educational issues. These reports should include not only the diagnosis and previous treatments, but also a summary report of what follow-up care you require. Specifically, what specialist appointments, radiology, laboratory, therapy visits, medications, educational interventions, and other treatment regiments you will need, when and how often.
If your child has educational needs or receives SNEA, reach out to the school and other specialists working with your child for recent documentation – ideally well before school staff departs for the summer break and much of the staff is not at school.
For individuals with a Domestic Assignment Only (Class 5) clearance we recommend you notify MED Clearances when it appears your medical, mental health or educational has stabilized and improved to the point where health care or educational needs can reasonably be obtained abroad. MED Clearances will reevaluate as to whether you could be issued a Post Specific (Class 2) or even a Worldwide Available (Class 1) Clearance.
Post Specific (Class 2) Medical Clearance Process for ESCAPE Posts
The process for completing a Post Specific (Class 2) medical clearance varies based on the employee’s employment status and where you are going. Please return to “Start Here” to click on the steps to a medical clearance that best fits your status and overseas assignment.
Post Approval Process for Foreign Service Officers, Limited Non-Career Assignment, Foreign Service Fellows or their Eligible Family Members with a Post Specific (Class 2) Clearance
Individuals with Post Specific (Class 2) medical clearances must be approved for their post of assignment. Early in the bidding season FSOs, LNAs and Fellows or their EFMs with a Post Specific (Class 2) clearance should submit their bid list or post choices to their State Department Career Development Officer (CDO) or agency human resources. Do NOT submit bids to Medical Clearances. CDOs will submit on behalf of State Department employees a bid list of no more than 10 countries. Additional countries can be submitted after the first have been reviewed. Do NOT include any personal medical information in this communication to HR, only the posts you wish to bid upon.
Your CDO or agency HR will send your list to MED Clearances. Do NOT submit your bids to MED Clearances.
A MED Clearances Clearance Consultant assigned to you will:
- Review the list of posts submitted by the CDO or agency HR.
- Submit internal consults or reach out to you for additional data, as needed.
- Consult the Medical Capabilities database and alternatively consult with post directly.
- Review posts with the clinicians in Clearances.
- Document rationale for Post Approvals and/or Disapprovals.
- Inform your CDO or Agency HR of approval determinations.
- Your CDO or Agency HR will notify you of posts you have been medically cleared for your next assignment.
Post Approval Process for employees of non-Foreign Service agencies, CONUS-based TDY, WAE/REAs, contractors and their EFMs with a Post Specific (Class 2) Clearance
Individuals with Post Specific (Class 2) medical clearances must be approved for their post of assignment. The post approval process for non-Foreign Service agencies, contractors and their EFMs mirrors the approval process for Foreign Service agencies. The primary difference is that the employee, contractor or EFM should list all potential posts directly on their medical clearance forms.
CONUS-based TDY and WAE/REA should list all known posts they will travel to. They will only need to submit once during the two years their clearance is valid. If a new post potentially arises, they should contact their Clearance Consultant for approval for that post.
The assigned Clearance Consultant will follow the same procedure outlined for Foreign Service officers above.
Medical Clearance Appeals Process
Employees, Contractors and EFM shave the right to appeal any medical clearance classification decision. If an employee wishes to contest a decision, they may contact the Medical Review Panel (MRP) at MEDMRP@state.gov and a review will be convened by a three-physician panel.
For further questions or information, please contact MEDClearances@state.gov or call 202-663-1519. Please send inquiries only to this email address.
Send all medical forms and reports to MEDMR@state.gov. Sending forms and reports to the wrong email address results in confusion.
The separation (or retirement) physical examination is for employees and eligible family members (EFMs) leaving the Foreign Service. This includes those who retire/separate, move to another agency, divorce an FSO, or age out of the MED program at age 21 years. This exam is recommended but not mandatory.
Separating FSOs intending on becoming a Retirement Annuitant (REA/WAE) should use their separation exam as their first-time WAE/REA physical.
Reasons for a Separation or Retirement Exam
The medical examination performed at the time of separation from the Medical Program serves to identify medical conditions that may have developed during service abroad. MED encourages you to have your exam at your future medical provider’s office to establish a medical relationship with a provider at your retirement home.
Separation Exam Process
Where to Perform a Separation Exam
- Private Provider: Employees and EFMs are encouraged to have the separation medical exam completed by their private medical provider in the US. This is an opportunity to establish or re-establish a professional relationship with your primary care provider.
- Post Health Unit: If you would like the examination at post, please contact your Health Unit or Foreign Service Medical Provider (RMO or MP) for guidance.
When to Do a Separation Exam
The employee and/or EFM should complete the separation exam within 90 days of retiring or separating from the Foreign Service. Travel orders are not required to start the process.
- A medical clearance is valid until your scheduled home leave or end-of-tour whichever is sooner.
- A CONUS based employee who does TDY travel for 30 or more consecutive days has a medical clearance valid for 2 years from the date it was issued.
- Individuals deploying to an ESCAPE post has a medical clearance valid for one year after arrival at post.
- Individuals extending at an ESCAPE post have a medical clearance valid for one year from the date of issuance.
- CONUS based individuals who do TDY travel to ESCAPE posts for 30 or more consecutive days have a medical clearance valid for two years from the date of issuance.
- A FSO candidate, LNA, Fellow or their EFM’s medical clearance is valid for five years from the date of the offer of employment to the start of their first tour. If individuals go beyond five years, they should contact their human resources.
- Individuals who have extended language or technical training have a medical clearance valid through the duration of their training and until the end of their onward overseas assignment.
- Individuals who have a linked assignment must have a medical clearance valid through the duration of their current assignment and until the end of their onward overseas linked assignment.
- Any medical clearance must be reviewed – and possibly modified – for the development of any new significant medical, mental health or educational issue. A CONUS based individual who does no TDY travel may delay reporting notification about the new condition until bidding on or being assigned to an overseas post.
During peak seasons MED Medical Records may take 10 business days to upload and index medical documents. This may be delayed if the individual is not properly registered, has missing signatures, incomplete documents, inaccurate email address or the writing is illegible.
It is important accompanying family members of tandem couples possess travel orders that match the sponsoring employee’s next post of assignment. Often children are under one parent’s orders for their current assignment and need to be switched to the other parent for an onward assignment.
MED Clearances strives to review an employee, contractor or EFM initial documentation within 30 days after documents have been uploaded and indexed by MED Records.
Individuals with no health issues should be notified after review that they have a Worldwide Available (Class 1) clearance.
Individuals who already have a Post Specific (Class 2) medical clearance or have a new significant medical, mental health or educational issue will need to supply documentation of the issues with status and treatment plan while abroad. The clearance process may take longer than 30 days if this additional information is not available to make a medical clearance decision. Those individuals will remain in a “pending” status.
Early summer through the fall bidding cycle is the busy season for MED Clearances. Waiting well into that time frame may result in a longer processing time.
You can determine you or your family member’s medical clearance status by:
- Clicking on “My Clearance Status” on the Customer Tools page of the MED Clearances SharePoint site, accessible via the Department of State’s OpenNet. This is accessible to Department of State Employees only.
- Contacting your Health Unit.
- Contacting your assignments officer in Human Resources for your agency. Not all agencies human resources have this capability.
- Contact Medical Clearances at MEDClearances@state.gov.