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Were you required to have a physical examination for entry into public service?

Yes

If yes, for what position did you have this physical and when?

Position: ___________________________________ Date:___________________ Employer:_______________________________________

If you did not have a physical exam for entry into public service, you MUST authorize the release of all relevant

medical records. Please complete the Medical Records Release Authorization below.

NOTE: If you did not undergo a physical exam for entry into public service, NYSLRS is required to have your authorization to satisfy the

requirements of the WTC Disability Law. It is recommended that you gather, maintain and/or submit relevant medical records as early as

possible. Doing so may help facilitate a disability application you may ﬁ le in the future.

MEDICAL RECORDS RELEASE AUTHORIZATION

I,__________________________________________________________________________, hereby authorize the release of all relevant

medical psychiatric, psychological, hospital and health insurance records, including specially protected or listed records such as those relating

to drug abuse, alcoholism, genetic testing, psychiatric care and/or conﬁ dential HIV/AIDS related information.

All pertinent records are authorized to be released to the New York State & Local Retirement System (NYSLRS) and will be used to determine

a WTC disability and/or death claim.

I understand that I have a right to revoke this authorization at anytime. I understand that if I revoke this authorization, I must do so in writing

and it may impact my ability to qualify for disability or accidental death beneﬁ ts provided under the WTC Disability Law.

By signing below I acknowledge that I have read and accept all of the above and hereby authorize any hospital, medical group, or other

organization to disclose all information to the New York State & Local Retirement System.

Signature _________________________________________________________ Date__________________________

I certify that the information contained on this form is true.

Signature (Sign Name in Full)

ACKNOWLEDGEMENT TO BE COMPLETED BY A NOTARY PUBLIC

State of ________________________________________________

County of _______________________________________

On the day _________ of ______________________________ in the year _________ before me, the undersigned, personally appeared

_______________________________________________________________________________, personally known to me or proved to me

on the basis of satisfactory evidence to be the individual(s) whose name(s) is (are) subscribed to the within instrument and acknowledged to me

that he/she/they executed the same in his/her/their capacity(ies), and that by his/her/their signature(s) on the instrument, the individual(s), or the

person upon behalf of which the individual(s) acted, executed the instrument.

NOTARY PUBLIC (Please sign and afﬁ x stamp)

*NOTE: In accordance with the Federal Privacy Act of 1974, you are hereby advised that disclosure of your Social Security account number is

mandatory pursuant to Sections 11, 34, 311 and 334 of the Retirement and Social Security Law. Your number will be used in identifying your

retirement records and in the administration of the Retirement System.

**Your Employer/Organization will be contacted to verify your involvement.

PERSONAL PRIVACY PROTECTION LAW – The Retirement System is required by law to maintain records to determine eligibility for and calculate

benefits. Failure to provide information may interfere with timely payment of benefits. The System may be required to provide certain information to

participating employers. The official responsible for record maintenance is the Director of Member Services, NYS and Local Retirement Systems,

Albany, NY 12244; 518-474-7736

RS 6047-N (Rev. 3/15)

Form Rs 6047-N - World Trade Center Notice For Members And Retirees Of The New York State And Local Retirement System Page 2

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