USMLE Accommodations

Q: Will residency programs know?

No. The USMLE states that score reports and transcripts will not include an annotation about test accommodations, and that no information about a request is released to a third party without written consent, subject to legal process.

Already denied? Read the USMLE reconsideration guide →

How do USMLE and COMLEX accommodation decisions work?

USMLE and COMLEX-USA accommodations are decided by the organizations that own those examinations, and they are among the most demanding accommodation processes a student will encounter. Department of Justice guidance expressly identifies medical licensing examinations, including clinical assessments, as covered by Section 309 of the Americans with Disabilities Act, 42 U.S.C. § 12189. The obligation applies regardless of how selective the profession is.

The stakes are unusual because these are not admissions tests. A failure or a delay affects clerkship scheduling, residency application timing, program eligibility, and in many programs academic standing itself. The exam sits inside a chain of consequences, which is why the accommodation timeline has to be planned backward from the program’s own deadlines rather than from the exam date alone.

Why medical students get denied

Three rationales appear repeatedly. The first is academic success: the candidate got into medical school and passed preclinical courses, so the reviewer concludes there is no substantial limitation. Federal guidance rejects that reasoning directly — a history of academic success does not mean a person lacks a disability requiring accommodations, and high achievement sustained by disproportionate time and effort is itself evidence of limitation.

The second is the absence of prior formal accommodations. Many medical students were never formally accommodated because they compensated successfully until the volume and pacing of board preparation exceeded what compensation could absorb. Guidance provides that the absence of previous accommodations does not preclude eligibility and that the entirety of the candidate’s history, including informal arrangements, should be considered.

The third is documentation: an evaluation judged too old, missing a preferred instrument, or insufficiently specific about functional limitation. Guidance provides that documentation demands must be reasonable and limited to the accommodation requested, that the entity should defer to a professional who individually assessed the candidate over an internal reviewer who did not, and that omitting one preferred subtest should not by itself defeat a request supported by the file as a whole.

School accommodations and board accommodations are separate decisions

Being accommodated by your medical school does not automatically produce accommodations on a licensing examination. They are different entities applying different processes. That said, the school record is powerful evidence: it reflects an individualized determination by professionals who assessed you, and it establishes continuity of need.

The practical implication runs in the other direction too. If you anticipate needing board accommodations, getting the school accommodation properly documented early — with the office’s written letter, not an informal arrangement with a course director — materially strengthens the later request. Informal kindness from faculty leaves no paper trail.

Accommodations beyond extended time

Additional or stop-the-clock break time, a separate testing room, permission to keep and take medication, blood glucose monitoring, food or drink at the station, an accessible or ergonomic workstation, screen magnification or contrast adjustment, and scheduling across multiple days for very long administrations. For clinical skills components, accommodations may involve the physical environment, equipment, timing between encounters, or communication supports.

Candidates with diabetes, inflammatory conditions, migraine disorders, seizure disorders, pregnancy-related conditions, chronic pain, or psychiatric conditions frequently need break and environment accommodations rather than, or alongside, extra time. Those requests are often documented most cleanly by the treating physician.

Timing, and the interaction with program requirements

Review takes time, denials happen, reconsideration takes more time, and testing windows are constrained. Meanwhile the medical school may have its own deadline for taking or passing the examination, and a delay can trigger a progression or promotions review. That is a genuinely difficult intersection, and it is worth raising the accommodation timeline with the school in writing early, so that a delay caused by the testing entity is documented rather than treated later as the student’s failure to progress.

Sitting unaccommodated to preserve a schedule is a decision with lasting effects. Attempts are counted, scores are reported, and accommodations are prospective. It should not be an emotional decision made under deadline pressure.

What should you do first?

Get the current requirements and forms directly from the examination program — for the USMLE, USMLE test accommodations; for COMLEX-USA, the current accommodations policy published by the examination’s administering organization. Standards and deadlines change by cycle, so use the program’s own page rather than any summary, including this one.

Then assemble your school disability services letters, evaluation reports, treating physician letters, prior standardized exam approvals, and any IEP or 504 Plan. If a denial has issued, obtain it in writing with its stated reasons, and put the school on written notice of the timeline before a progression deadline arrives.

What can a student defense lawyer do here?

Reviewing the program’s current documentation standards against the file you hold
Organizing school disability services records and prior exam approvals
Building a request around functional limitation rather than diagnosis alone
Framing break, environment, and medication accommodations, not only extended time
Identifying the exact ground stated in a denial and what has to be answered
Assisting with the reconsideration or appeal, to the extent the program permits
Addressing the interaction between a delayed exam and program progression deadlines

What form that assistance takes depends on the program’s current rules about communicating with a representative, and on your school’s policy where progression is also in play.

Accommodations on the other exams

Each testing agency sets its own deadlines, documentation standards and appeal routes, and an approval on one exam does not carry to the next. These pages set out the procedure for each:

How the USMLE process actually runs

One point first, because it saves people a wasted phone call: NBME Disability Services decides accommodations for all three Steps, including Step 3 — even though Step 3 registration runs through the FSMB. Requests go through the MyUSMLE portal. There is no paper form any more, and no fee.

Sixty business days, and the clock is tied to your eligibility period. The USMLE asks candidates to allow roughly 60 business days for a decision. Requests are processed in the order received and cannot be expedited. A narrow lane runs faster — about 14 business days — for additional break time with standard testing time, personal items, and subsequent requests for accommodations identical to ones already approved.

Two timing traps are worth planning around. Processing only begins once your Step application is complete and your registration is current. And if your eligibility period expires before you have submitted the request and supporting documentation, Disability Services cannot process it at all. The USMLE’s own worked example is instructive: for a June–August eligibility period, it suggests submitting no later than early March. When you request accommodations at registration, your scheduling permit is placed on hold until the decision issues.

What the documentation has to show — and one rule that is more generous than people expect

The evaluating professional should be licensed with training and direct experience diagnosing and treating adults in the specific area of disability. Beyond that, the USMLE’s recency rules are narrower than most guides suggest. A six-month currency requirement applies to psychiatric conditions only. For ADHD and specific learning disorders the published guidelines impose no numeric recency limit — the standard is simply documentation dated within a reasonable timeframe sufficient to show current impairment. Any source telling you the USMLE enforces a blanket three-year or five-year rule is describing something that is not in the current guidelines.

What the file must contain is a description of the full extent of your current functional limitations in daily life and under standard testing conditions. The USMLE says plainly that having a diagnosis alone does not automatically qualify anyone for accommodations. For a learning disorder it wants assessment data from a comprehensive battery of standardized, norm-referenced tests. For ADHD it wants a rationale addressing why the specific accommodation is needed — for instance why additional testing time rather than additional break time or a separate room.

The provision most worth knowing about is for candidates with no accommodation history at all. The USMLE personal statement expressly invites it: if you have no history of using an accommodation, or are asking for one you have never used, explain why it is necessary now but was not needed previously. The program states that it considers all factors whether you have extensive historical records or limited ones due to a recent diagnosis. A late diagnosis is not the disqualifier candidates fear it is.

Prior accommodations still help. The USMLE lists official score reports from nationally normed tests (SAT, ACT, MCAT, LSAT, GRE, GMAT, licensing exams) and official records of approved accommodations from schools, including Section 504 plans and IEPs, among the objective evidence it accepts.

Reconsideration — one shot, inside the window

You get one reconsideration per active registration, and only while you have not tested and your scheduling permit has not expired. It must present new and substantive documentation or information not already reviewed; letters that restate what was already sent are generally not sufficient. Helpfully, the USMLE says it does not ask candidates to undergo new or redundant evaluation to seek reconsideration — it will consider new objective evidence. A reconsideration runs the full ~60 business days, so it has to be launched early enough to land inside the eligibility window.

There is no external or independent appeal published. After one internal reconsideration, the remaining route is litigation.

Will residency programs know?

No. The USMLE states that score reports and transcripts will not include an annotation about test accommodations, and that no information about a request is released to a third party without written consent, subject to legal process.

What the numbers show

The USMLE publishes its own approval statistics, which is unusual and useful. Requests approved fully or partially: 76% (2020), 83% (2021), 86% (2022), 94% (2023), 92% (2024). Read that figure carefully, though, because the USMLE defines it broadly — it counts partial approvals, including cases where a candidate was approved for less additional time than requested, or for additional break time instead of additional testing time. A partial approval is recorded as an approval.

Volume has risen sharply: total requests across all Steps went from 1,720 in 2020 to 6,344 in 2025. No approval rate has been published for 2025 or 2026.

The case that changed how these denials are judged

In Ramsay v. National Board of Medical Examiners, 968 F.3d 251 (3d Cir. 2020), the Third Circuit affirmed an injunction requiring the NBME to give a medical student double testing time on Step 1. Four holdings matter to anyone in this position.

First, the comparison is to most people in the general population — not to other medical students, and not to other people with the same condition. Second, academic achievement does not defeat a disability finding: someone with a learning disability may achieve a high level of academic success and still be substantially limited, because of the additional time and effort reading or writing costs them; hard work and study habits are mitigating measures, which the statute excludes from the analysis. Third, past accommodations bear on whether the person is disabled, not merely on what to grant. Fourth, a court may credit the clinicians who actually examined the candidate over an agency’s record-reviewing consultants, and the agency must explain why the treating professionals are unworthy of credence.

One correction worth making, because it circulates widely: the Department of Justice’s 2011 settlement with the NBME expired in February 2014, as the Third Circuit confirmed. It no longer binds the NBME. What survives is the regulation itself, 28 C.F.R. § 36.309, which is binding on its own force and says much the same things.

The law behind a testing accommodation request

Testing agencies write their own procedures, but they do not write the standard. Section 309 of the Americans with Disabilities Act, 42 U.S.C. § 12189, requires that any person offering an examination related to licensing, certification or credentialing offer it in a place and manner accessible to people with disabilities. Because the statute says “any person” rather than any private entity, it reaches the private testing companies — LSAC, the AAMC, ETS, GMAC, NCBE — and public bodies alike. That point is settled, and Florida has its own authority on it: in Florida Board of Bar Examiners re S.G., 707 So. 2d 323 (Fla. 1998), the Supreme Court of Florida applied the ADA to the administration of the Florida Bar Examination.

“Best ensure” is a higher standard than “reasonable accommodation”

The implementing regulation, 28 C.F.R. § 36.309(b)(1)(i), requires that an examination be selected and administered so as to best ensure that the results reflect the candidate’s aptitude or achievement rather than the disability. That is a stronger obligation than the “reasonable accommodation” standard people know from the employment context, and the difference is deliberate — Congress did not import the employment standard into § 12189.

The leading decision is Enyart v. National Conference of Bar Examiners, 630 F.3d 1153 (9th Cir. 2011), which gave the regulation deference and held that accessibility means an equal opportunity to demonstrate knowledge or ability to the same degree as candidates without disabilities. Courts have explained why the standard is more demanding here than at work: an employer can adjust an accommodation over months, but a licensing examination is a single event at which the accommodation either delivers equality or does not. The limit on the other side is that no agency must make a change that would fundamentally alter what the examination measures — 28 C.F.R. § 36.309(b)(3), applied in S.G.

What the regulation says about your paperwork

Two subsections are worth knowing by number, because they are the answer to the two most common denials.

§ 36.309(b)(1)(iv) — a request for documentation must be reasonable and limited to the need for the accommodation requested. A demand for a full battery of testing to support a request for extra breaks is not obviously proportionate to that need.

§ 36.309(b)(1)(v) — an agency must give considerable weight to documentation of past accommodations received in similar testing situations, and to accommodations provided under an IEP or a Section 504 plan. The Department of Justice’s guidance published with the regulation is unusually direct about why: it says that where a student has had a Section 504 plan since middle school providing extra time and a quiet room and seeks the same accommodations, “a testing entity receiving such documentation should clearly grant the request for accommodations,” and explains that the provision was added because such decisions “are often discounted and ignored by testing entities.”

Be clear-eyed about the limits, though. Whether a candidate can sue on the “considerable weight” provision standing alone has not been decided by any court of appeals — it is unsettled. And a history of accommodations is not automatically decisive: Cox v. Alabama State Bar, 330 F. Supp. 2d 1265 (M.D. Ala. 2004), held that receiving an accommodation elsewhere does not by itself make the same accommodation required on a bar examination. The provision is powerful as leverage and as evidence; it is not a guarantee.

Good grades do not disprove a disability

The most common reason a strong candidate is refused is that they did well anyway. The ADA Amendments Act of 2008 addressed this directly: under 42 U.S.C. § 12102(4), the definition of disability is construed in favor of broad coverage, and whether an impairment substantially limits a major life activity is decided without regard to the ameliorative effects of mitigating measures. The compensating strategies a bright student builds — rereading everything twice, working through the night, avoiding timed conditions — are mitigating measures, and they cannot be used to prove the limitation away. Congress passed the amendments precisely to overturn the narrow reading the courts had adopted.

One honest caveat, because it decides real cases: the comparison is to most people in the general population, not to a candidate’s own potential. In Rawdin v. American Board of Pediatrics, 985 F. Supp. 2d 636 (E.D. Pa. 2013), a physician with a very high IQ was held not substantially limited in test-taking because his performance was not below that of the average person. A file built only on the gap between ability and score is weaker than one built on functional limitation against an ordinary baseline.

Suing a bar examiner is harder than suing a testing company

This distinction matters more than any other on this page. A private testing agency can be sued under Title III for injunctive relief. A state board of bar examiners is a different proposition.

In T.W. v. New York State Board of Law Examiners, 110 F.4th 71 (2d Cir. 2024), the Second Circuit held that Title II of the ADA does not validly abrogate a state’s Eleventh Amendment immunity in the professional-licensing context, reasoning that the right to practice a chosen profession draws only rational-basis review and that Congress documented no pattern of unconstitutional discrimination in licensing. The Ninth Circuit reached the same conclusion, sitting en banc, in Kohn v. State Bar of California, 87 F.4th 1021 (9th Cir. 2023).

The Eleventh Circuit, which covers Florida, has not decided the question. Its most relevant decision, Dale v. Moore, 121 F.3d 624 (11th Cir. 1997), threw out a Florida bar applicant’s ADA claim on Rooker-Feldman grounds — because the Supreme Court of Florida had already ruled, the federal claim was inextricably intertwined with that ruling — without reaching immunity at all. Stoddard v. Florida Board of Bar Examiners, 509 F. Supp. 2d 1117 (N.D. Fla. 2006), held the Eleventh Amendment bars non-ADA damages claims against the Board and its members in their official capacities.

What survives is real but narrower than people expect. Ellen S. v. Florida Board of Bar Examiners, 859 F. Supp. 1489 (S.D. Fla. 1994), held that the ADA does apply to the Board’s admission functions, that state-law authority is no shield against federal law, and that a board can discriminate by placing additional burdens on disabled applicants even where it eventually admits them. Prospective injunctive relief against individual board members under Ex parte Young remains available where the claim is pleaded as an ongoing or anticipated violation rather than a complaint about a decision already made. Section 504 of the Rehabilitation Act is worth considering separately, because a federal-funding condition can waive immunity that the ADA does not reach.

The practical consequence is about sequence, and it is the most useful thing on this page. A retrospective federal lawsuit filed after the Supreme Court of Florida has acted runs into Rooker-Feldman, Younger abstention and the immunity problem all at once. The time to act is while the administrative route is still open and the violation is still ongoing — not after the last internal door has closed.

This page describes how these processes work in general. It is not legal advice about your situation, and no outcome can be promised in any individual case.

Common questions about USMLE and COMLEX accommodations

My school accommodates me. Is that enough for the boards?

Not automatically, because they are separate decisions by separate entities. The school record is strong evidence, though, and should always be part of the submission.

I have never had accommodations before. Am I out of luck?

No. The absence of prior formal accommodations does not preclude eligibility, and the entirety of your history, including informal arrangements, is supposed to be considered.

The reviewer said my grades show no limitation. Can that be challenged?

Yes, and federal guidance rejects that reasoning. The answer is evidence about how the performance was actually produced and at what cost, which turns on the facts of your history.

My program has a deadline to pass. What do I do?

Put the accommodation timeline in writing with the school early, so a delay is documented at the time rather than reconstructed later. A lawyer should advise you on the issues and the facts before you agree to any deadline extension terms.

How soon should I get advice?

As early as possible, because these reviews are slow and the surrounding deadlines are not. A flat-fee Full Read + Game Plan is described on the Fees and Scope of Services page.

Other exam accommodations: MCAT accommodations, NCLEX accommodations, and bar exam accommodations. The full list is on the exam accommodations index.

Osteopathic students: every DO campus in Florida is listed in the Florida osteopathic medical schools section of the Florida schools index. A COMLEX accommodation request is separate from anything your campus approved, and it is filed with the NBOME on the NBOME’s timeline.

This is general information about the matters I handle and the law that applies to them. It is not legal advice about your situation, and the law in this area can change. For advice on your matter, start with the Full Read + Game Plan — your entire file read, straight answers, and exactly what to do next, in what order.

This page is informational and is not affiliated with, endorsed by, or sponsored by any testing program named on it.