When an individual requests withdrawal of Premium-HI enrollment, be sure that the
individual realizes the consequences of the action by following the guidelines in
HI 00805.080 and HI 00820.045 – HI 00820.075 for SMI withdrawal and termination requests. Also, make sure the individual is aware
of the QMB provisions (see HI 00801.139) if requesting withdrawal because of inability to pay premiums.
If, after receiving a full explanation of the consequences of withdrawal, the individual
still wishes to withdraw, obtain complete form CMS-1763 (Request for Termination of
Premium Hospital Insurance and/or Supplementary Medical Insurance), clearly documenting
reasons for making the request.