It just sets one flag in the .exe to let Windows know it doesn't assume anything stupid about memory addressing and can use up to 2
32 bytes, or 4 gigabytes of memory without failing. Without that flag Windows will refuse further memory allocation if the game's memory footprint would go past 2 GB.
Yes, it will work automatically if you have a 64-bit system or a 32-bit one configured to grant the userspace more than 2 GB (Google "/3gb" if you are running a 32-bit system with more than 2 GB RAM for some reason). The most notable effect is not crashing as easily at high settings or lots of mods.