Tier 6 63/10 and Special Plan Members Form #624 - New York City ... 2026

1. Click ‘Get Form’ to open it in the editor.
2. 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.
3. 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.
4. List your disabling conditions clearly in the designated field. Remember, these are the only conditions that will be considered by the Medical Board.
5. Choose one temporary option regarding your benefits. Carefully read each option's description before making a selection.
6. Complete the beneficiary information if applicable. Ensure all details are accurate and printed neatly.
7. Sign and date the form. Make sure to have it notarized as required before submission.

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