ECFMG certification for international medical graduates: requirements, Pathways, OET, fees and timeline

ECFMG certification is the credential every international medical graduate (IMG) needs before starting an ACGME-accredited residency or fellowship in the United States, and before sitting USMLE Step 3. You earn it by meeting four requirements, all verified by ECFMG: your medical school and graduation year are eligible, ECFMG has confirmed your final medical diploma and transcript directly with your school, you have passed USMLE Step 1 and Step 2 CK, and you have an accepted Pathway, which includes passing OET Medicine at 350 in Listening, Reading and Speaking and 300 in Writing.

For the 2027 Main Residency Match, the deadline that matters most is January 31, 2027: that is the last day (Eastern Time) to submit a 2027 Pathways application. ECFMG's own fees come to $1,855 for most applicants ($110 account, $580 application, $220 credential verification, $945 Pathways application), before USMLE, OET, travel or ERAS. A certificate earned through a 2027 Pathway expires on December 31, 2029 unless you revalidate or it becomes permanently valid through US training or licensure.

This guide covers the certification itself: eligibility, the application, credential verification, every Pathway, the OET rules, expiry and permanent validation, costs and a realistic timeline. The exams are covered in depth in our USMLE guide for international medical graduates, and degree verification for other regulators in our EPIC verification guide. All figures were checked on ECFMG, USMLE and NRMP pages on October 29, 2026.

ECFMG (the Educational Commission for Foreign Medical Graduates) is a division of Intealth, a nonprofit that also includes FAIMER. Its certification program assesses whether graduates of medical schools outside the United States and Canada are ready to enter US graduate medical education. Our ECFMG overview lists all of its services, from certification to J-1 sponsorship and EPIC.

Three points cause the most confusion:

• It is not a license. State medical boards issue medical licenses. ECFMG certification makes you eligible to enter accredited residency and to sit Step 3, and state boards then use it as one of their licensing requirements. The full picture for doctors is on our page on working as a doctor in the USA.
• ECFMG no longer runs USMLE registration. Since January 12, 2026, the Federation of State Medical Boards (FSMB) handles all USMLE Step exam services for IMGs: registration, score reports and customer service. You apply for Step 1 and Step 2 CK through FSMB. ECFMG still handles the certification application, credential verification, the Pathways and the certificate.
• Step 2 CS no longer exists. USMLE discontinued the Step 2 Clinical Skills exam in 2021. ECFMG replaced it with the Pathways, which test clinical skills and communication skills in other ways. Many guides still tell IMGs to book Step 2 CS or to register for USMLE through ECFMG; both are out of date.

Who needs it: anyone who graduated, or will graduate, from a medical school outside the United States and Canada and wants ACGME-accredited training, whatever their citizenship. US citizens who studied abroad (for example in the Caribbean) need it as well. If you only want licensure in another country, you do not need ECFMG certification, though regulators such as the GMC in the UK and the Medical Council in Ireland use ECFMG's separate EPIC service to verify your degree.

Before paying anything, look up your medical school in the World Directory of Medical Schools and open the Sponsor Notes tab. ECFMG says that if there is no ECFMG Sponsor Note on your school's listing, its students and graduates are not eligible for ECFMG certification. The note also lists the graduation years it covers, and your graduation year must be included. A school can appear in the World Directory and still not cover your year, so read the dates, not just the name.

• Current students must be at a school whose Sponsor Note shows "Current" for graduation years.
• Graduates need the same listing and a graduation year inside the note's range. ECFMG's 2026 Information Booklet also sets rules on transfer credits, including how many credit years must come from listed schools; read them if you moved between schools.
• Only school officials can ask ECFMG for a Sponsor Note. Students and graduates cannot request one on the school's behalf.

You will also see a separate Intealth marker for the Recognized Accreditation Policy, which Intealth began implementing in November 2024. A school meets it if it is accredited by an agency recognized by the World Federation for Medical Education (WFME) or found comparable by the US National Committee on Foreign Medical Education and Accreditation (NCFMEA). Intealth says this policy does not by itself affect an individual's eligibility for ECFMG certification. It does matter for the Pathways, though: Pathway 3 depends on WFME-recognized accreditation and Pathway 4 on NCFMEA comparability, as explained below.

Everything runs through MyIntealth, ECFMG's online portal. The order is fixed:

1. Open a MyIntealth account ($110). The fee includes $50 for online notarization of your Intealth Identification Form through NotaryCam. A licensed US notary checks your identity against your passport in a live online session. If you cannot use NotaryCam, ECFMG allows in-person notarization, which you arrange yourself. Use your name exactly as it appears on your passport and diploma; name mismatches between documents are one of the most common reasons files stall.
2. Submit the Application for ECFMG Certification ($580). This is a one-time application that opens your certification file. You can submit it while still a student. Your application must reach a status of Accepted or Pending Credential Verification before you can apply to a Pathway.
3. Request credential verification ($220). This is $110 for your final medical diploma and $110 for your final medical school transcript, covered in the next section.

The account and application fees above are those for requests submitted on or after April 1, 2026, when ECFMG raised most of its fees. Older blog posts quote lower amounts. ECFMG does not accept paper documents by mail or email for certification; you upload them in MyIntealth.

ECFMG verifies your final medical diploma and final medical school transcript directly with your medical school. This is primary source verification: ECFMG sends the documents to the school and waits for an official confirmation that they are genuine. You cannot be certified until both are verified, and you cannot submit a final diploma until it has been issued, which is why students often have every exam passed but still wait for certification after graduation.

Item	Fee	What can delay it
Final medical diploma verification	$110	School slow to respond; name on diploma differs from passport
Final medical school transcript verification	$110	Transcript missing courses or dates; transfer credits not shown
Translation by ECFMG	$52 per page	Charged only if you do not provide an acceptable English translation

Most of the waiting is on the school's side. Before you upload, contact the dean's office or registrar, check they know how to respond to ECFMG requests, and ask how long they usually take. If your school has closed or merged, contact ECFMG early, because verification still has to come from an official source.

Certification verification versus EPIC. Credential verification for ECFMG certification is part of the certification file. EPIC is a separate ECFMG service that verifies credentials for other organizations, such as the GMC, the Medical Council in Ireland and some US state boards. If you plan to keep options open in the UK or Ireland as well, read our EPIC guide before you start, since some documents can be verified once and reported to several organizations.

The medical science requirement is a pass on USMLE Step 1 and Step 2 Clinical Knowledge (CK). You apply through FSMB and test at Prometric centers in the United States or abroad. USMLE lists these fees for 2026 and 2027:

Exam	Fee	Region fee outside the US and Canada
Step 1	$695	$210
Step 2 CK	$695	$235
Step 3 (after certification, US only)	$955	Not applicable

USMLE adds an 18% tax for Step 1 and Step 2 CK taken in India. Step 1 is reported as pass or fail; Step 2 CK gives a three-digit score that residency programs weigh heavily. Formats, attempt limits and preparation are covered in our USMLE guide.

The seven-year rule. ECFMG requires you to meet all examination requirements within a maximum of seven years, counted from the date of the first exam you pass. The window closes on the same calendar date seven years later. If you miss it, your earliest passing result is no longer valid for certification, and you may have to retake that exam. ECFMG says it will not notify you of upcoming deadlines, so note your date the day your first result arrives. The Pathways sit outside this rule: an expired Pathway can be revalidated even after the seven-year period.

The Pathways are how IMGs meet ECFMG's clinical skills and communication skills requirements. ECFMG published the 2027 Pathways and opened the application on May 15, 2026. The application costs $945, is not refundable, and for the 2027 Match must be submitted no later than January 31, 2027, Eastern Time. Every Pathway also requires an OET Medicine pass (next section).

Pathway	Who it is for	Key 2027 conditions
Pathway 1	Licensed physicians	You have held a license or registration to practice medicine without supervision in any country at any time on or after January 1, 2022. A training, resident or restricted license does not count. If you qualify, you must use Pathway 1.
Pathway 2	Graduates of schools with a national licensing OSCE	Your school administers an OSCE that the country's medical regulatory authority requires for licensure, and you passed it. Graduation on or after January 1, 2024.
Pathway 3	Schools accredited by a WFME-recognized agency	Graduation on or after January 1, 2024, plus a Clinical Skills Attestation from your school.
Pathway 4	Schools accredited by an NCFMEA-comparable agency	Graduation on or after January 1, 2024, plus a Clinical Skills Attestation.
Pathway 5	Joint MD programs with a US school	Your MD is issued jointly with a US medical school accredited by the LCME. Graduation on or after January 1, 2024, plus a Clinical Skills Attestation.
Pathway 6	Everyone else	Six in-person clinical encounters rated on ECFMG's Mini-CEX by licensed physicians. Required for anyone who ever failed Step 2 CS.

Pathway 1 in practice

Each licensing authority must confirm your license and any disciplinary history to ECFMG. ECFMG prefers a Certificate or Letter of Good Standing sent directly by the regulator, and the verification must reach ECFMG no later than January 31, 2027. Allow for slow regulators: request the certificate as soon as you decide to apply, and check ECFMG's current instructions on how recent it must be.

Pathways 2 to 5 in practice

ECFMG publishes a list of medical schools eligible for the 2027 Pathways 2 to 5. Check it, because the criteria are school-level and ECFMG states there are no exceptions. For Pathway 2, if your final diploma has not been issued yet, your school must send an OSCE Attestation that ECFMG receives by January 31, 2027; once the diploma is issued, ECFMG verifies it directly instead. For Pathways 3 to 5, your school completes a Clinical Skills Attestation: by February 15, 2027 through ECFMG's online portal, or by January 31, 2027 on the paper form if the school does not use the portal. ECFMG says a letter or other document from your school does not meet the requirement.

Pathway 6 is the route for graduates who do not fit Pathways 1 to 5, including most graduates who finished before 2024 and have never held a full license. It is also the only option if you failed Step 2 CS at any point. Instead of a school attestation or a license, you need six real, in-person clinical encounters, each evaluated by a licensed physician on ECFMG's electronic Mini-Clinical Evaluation Exercise (Mini-CEX).

• Evaluators: each must hold a full, unrestricted license and have held it for at least five years. Each evaluator may assess no more than two of your six encounters, so you need between three and six evaluators. Evaluators cannot be relatives, cannot be paid by you, and may evaluate no more than 10 applicants in the 2027 season.
• Setting: a formal outpatient primary care setting. ECFMG does not accept telemedicine, virtual or standardized patient encounters, nor emergency room, urgent care or inpatient encounters.
• Scoring: evaluators rate four components on a 1 to 9 scale, where 4 to 6 reflects the level of a new medical school graduate. ECFMG averages each component across all six evaluations.
• Deadline: all six completed evaluations must reach ECFMG by February 15, 2027. Evaluations from the 2026 season cannot be reused.

The practical difficulty is finding evaluators, often through observerships or clinical experiences in US outpatient practices. Be wary of anyone who charges you for Mini-CEX evaluations: ECFMG's rules forbid evaluators from being paid by the applicant, and an evaluation that breaks the rules can cost you the season.

OET Medicine is the only English and communication test ECFMG accepts for certification. IELTS and TOEFL do not count, and there is no exemption for native English speakers or for graduates of English-medium schools. This differs from the UK and Ireland, where regulators accept several tests (see our comparison of IELTS and OET for UK regulators).

Sub-test	Minimum score for ECFMG
Listening	350
Reading	350
Speaking	350
Writing	300

• All four scores must come from one test administration. If you miss one, you retake all four.
• For the 2027 Pathways, the test must be taken on or after January 1, 2025.
• Take OET on paper or on computer at a test venue. OET@Home is accepted only if there is no venue in your country.
• Give OET your MyIntealth ID so results go to ECFMG automatically. Results usually come about 10 business days after the test, and ECFMG says to allow three business days for them to show in your Pathways application.
• ECFMG recommends testing no later than the last OET test date in December 2026 for the 2027 Match.

Some guides online say ECFMG needs "grade B in all four sub-tests". That is not ECFMG's rule: Writing has a lower threshold (300), and the numbers above are the ones ECFMG publishes.

Once every requirement is met and verified, ECFMG issues a Standard ECFMG Certificate, usually about two weeks after the final requirement is met. ECFMG treats the issue date on the certificate as the date you became certified. Residency programs confirm your status through ECFMG's Certification Verification Service (CVS) at no cost; a CVS report sent to a state medical board costs $70.

Pathway-based certificates expire. An accepted Pathway expires based on the season it was accepted for, and a certificate earned through a Pathway expires with it. A 2027 Pathway expires on December 31, 2029. That matters for two reasons ECFMG gives: to take part in the NRMP Match you need an accepted, unexpired Pathway at the Rank Order List certification deadline, and you need a valid certificate to start ACGME-accredited training (and to sit Step 3).

Situation	What ECFMG says to do
Pathway expired or expiring, not yet in training	Submit a 2027 Pathways Revalidation application ($945). Revalidation is only through Pathway 1 or Pathway 6, with a new OET Medicine result taken on or after January 1, 2025. If accepted, ECFMG extends the certificate to December 31, 2029 without issuing a new copy.
At least 12 months of ACGME-accredited training completed	The certificate can become permanently valid. Trainees not sponsored on an Intealth J-1 submit a request through their program director.
Holding an unrestricted US medical license	Request permanent validation; ECFMG verifies the license with the issuing authority.
Already in a program, certificate expiring before permanent validation	Contact ECFMG about extending validity; ECFMG says not to use Pathways Revalidation.

Certificates based on the old Step 2 CS exam do not carry this expiry. If you pass every exam but do not match, plan your next attempt around your Pathway's expiry date as well as the seven-year exam window.

These are the fees ECFMG and USMLE publish for 2026 to 2027. OET, preparation courses, travel and document fees charged by your school are extra and vary.

Item	Fee	Paid to
MyIntealth account (includes $50 NotaryCam)	$110	ECFMG
Application for ECFMG Certification	$580	ECFMG
Credential verification (diploma and transcript)	$220	ECFMG
2027 Pathways application	$945	ECFMG
USMLE Step 1, outside the US and Canada	$695 + $210	FSMB
USMLE Step 2 CK, outside the US and Canada	$695 + $235	FSMB
Total, testing abroad, one attempt each	$3,690	Before OET and other costs

After certification, IMGs also buy an ERAS token from ECFMG ($185 for the 2027 season), pay AAMC application fees and NRMP registration ($85), and, if they need it, apply for ECFMG J-1 sponsorship ($370 plus a $220 SEVIS fee for initial applicants).

A realistic timeline

• Weeks 1 to 4: check your Sponsor Note, open MyIntealth, complete notarization and submit the application and credential verification. School response times decide how fast verification moves.
• Months 2 to 12: prepare for and pass Step 1 and Step 2 CK. USMLE results usually arrive two to four weeks after the test, but USMLE advises allowing at least eight weeks when you plan.
• By December 2026 (for the 2027 Match): pass OET Medicine and line up Pathway documents, license verifications or Mini-CEX evaluators.
• By January 31, 2027: submit the Pathways application. ECFMG says to allow about five business days for a case manager to begin review and five more for final review once all documents are in.
• March 2027: the NRMP Rank Order List deadline is March 3, 2027 and Match Day is March 19, 2027. For the 2027 Match, all exam requirements must be met by the Rank Order List certification deadline.

Most independent guides estimate 12 to 24 months from first exam to certificate. The real limits are your exam preparation and your school's speed in answering ECFMG.

Certification opens the door to the Match, not a job. Most IMGs who are not US citizens or permanent residents train on a J-1 visa sponsored by ECFMG or on an H-1B sponsored by the hospital; each has very different consequences after training. Step 3 becomes available once you hold a valid certificate and is taken only in the United States. For how certification fits next to nursing and other professions, see our guide to US healthcare careers, and for doctors in all five destination countries, our doctors hub.

If you are licensed and working in the Gulf (DHA, DOH, MOHAP, SCFHS, QCHP or similar):

• A full, unsupervised Gulf license held at any time on or after January 1, 2022 makes Pathway 1 compulsory for you, unless one of ECFMG's stated exceptions applies. Ask each authority you have been licensed by to send a good standing certificate directly to ECFMG, and allow time, since some take weeks.
• If you also hold a license from your home country, that counts as well, and each relevant authority may need to confirm your record.
• ECFMG verifies your diploma and transcript itself, directly with your medical school, so start that early even if a Gulf authority has already had them verified.
• Gulf clinical experience does not replace USMLE or OET, but it can strengthen your residency application, especially when supported by US clinical experience.

Weighing the USA against other destinations? The UK route through PLAB is in our PLAB and GMC registration guide, and Ireland's exam route in our PRES guide. Both use EPIC, so verification you complete for ECFMG work is rarely wasted.