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F606 NYCERS USE ONLY Physician s Report of Disability To be returned to NYCERS with member s application for disability retirement To NYCERS Medical Board This is to certify that First Name M. I. Last Name an employee in the New York City Department of is under my care for the following Diagnosis Clinical problem and duration If caused by an accident Type Place and Date Date MM/DD/YYYY / When if ever may he or she return to the full duties of his or her title Objective evidence X-Rays EKG Photocopies Laboratory Reports Pertinent physical findings Consultant Reports Hospital Reports Etc* Symptoms Complaints Etc* Treatment and result R06/08/11 Page 1 of 2 Member Number Physician First Name Last 4 Digits of SSN Physician Last Name Title MD DO DC etc* Address Apt. Number City State Signature of Physician Zip Code Applicant s Authorization for Release of Information Dear Doctor you are hereby authorized by me to fill out this form for the information of the Medical Board of the New York City Employees Retirement System* Signature of Applicant in Care of if applicable Full Social Security Number. I. Last Name an employee in the New York City Department of is under my care for the following Diagnosis Clinical problem and duration If caused by an accident Type Place and Date Date MM/DD/YYYY / When if ever may he or she return to the full duties of his or her title Objective evidence X-Rays EKG Photocopies Laboratory Reports Pertinent physical findings Consultant Reports Hospital Reports Etc* Symptoms Complaints Etc* Treatment and result R06/08/11 Page 1 of 2 Member Number Physician First Name Last 4 Digits of SSN Physician Last Name Title MD DO DC etc* Address Apt. Number City State Signature of Physician Zip Code Applicant s Authorization for Release of Information Dear Doctor you are hereby authorized by me to fill out this form for the information of the Medical Board of the New York City Employees Retirement System* Signature of Applicant in Care of if applicable Full Social Security Number.

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