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Tier 6 63/10 and Special Plan Members Form #624 - New York City ... 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by filling out your personal information in the 'Member Information' section, including your Member Number, last four digits of your SSN, date of birth, phone number, and address.
- Select the benefits you are applying for by checking the appropriate boxes under 'Select a Benefit'. Ensure you read the requirements on the Instructions and Terms pages.
- List your disabling conditions clearly in the designated field. Remember, these are the only conditions that will be considered by the Medical Board.
- Choose one temporary option regarding your benefits. Carefully read each option's description before making a selection.
- Complete the beneficiary information if applicable. Ensure all details are accurate and printed neatly.
- Sign and date the form. Make sure to have it notarized as required before submission.
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