Are you a Nycer looking to complete the F170 form? If so, then you’re in the right place! Completing this form is essential for any New York City resident trying to get coverage through MetroPlus Health Plan, and it can be daunting. This blog post will provide a comprehensive guide on how to fill out your F170 correctly, including everything from start date options to tax season considerations. We’ll also discuss other important information that should be taken into account when navigating the NYC healthcare system. Read ahead for all of the details — rest assured that by following our steps you’ll have your application processed effortlessly and quickly.
| Question | Answer |
|---|---|
| Form Name | Nycers Form F170 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | EMT, SSN, john murphy nycers, NYC |
NYCERS USE ONLY |
F170 |
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*170*
Election of Optional EMT
Tier 1, Tier 2 or Tier 4 Members
This is an election for Tier 1 and Tier 4 members to participate in the
Member Number |
Last 4 Digits of SSN |
Home Phone Number |
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Work Phone Number
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First Name |
M.I. |
Last Name |
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I understand that in order for this election to be valid pursuant to law, I must:
1.have become an EMT member after December 8, 2000
2.file this election form within 180 days of becoming an EMT Member
If you were an active EMT member on December 8, 2000, you had the option of joining this program by filing this application by June 6, 2001; however, this option has since expired.
*EMT Member: A member of NYCERS while employed by the City of New York or the NYC Health & Hospitals Corporation in a title whose duties are those of an Emergency Medical Technician (EMT), or Advanced EMT (AEMT) or in a title whose duties require the supervision of employees whose duties are those of an EMT or AEMT
ONCE THIS ELECTION IS RECEIVED BY NYCERS IT CANNOT BE REVOKED
Sign this form and have it notarized, page 2
R08/03/11 |
Page 1 of 2 |
F170
Member Number |
Last 4 Digits of SSN |
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I hereby elect to participate in the Tier 1 or Tier 4 Optional
Signature of Member |
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This form must be acknowledged before a Notary Public or Commissioner of Deeds |
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before me the above named, |
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, to me known, and known to |
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me to be the individual described in and who executed the foregoing instrument, and he or she acknowledged to me that he or she executed the same, and that the statements contained therein are true.
Signature of Notary Public or Commissioner of Deeds
Official Title
Expiration Date of Commission
HAVE YOU MOVED RECENTLY?
Old Address |
New Address (check box if same as on page 1) |
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Sign this form and have it notarized, THIS PAGE
R08/03/11 |
Page 2 of 2 |