HI 00630.070 Processing by the Modules - Medicare Outside U.S.
Upon receipt in the modules an acknowledgement letter (SSA-457 for domestic beneficiaries
and SSA-L457FC for foreign beneficiaries) will be sent to each person requesting SMI
termination. However, no notice will be sent if the effective date of the withdrawal
has passed. OCRO will send a computer termination notice when the request is processed.
The modules will be responsible for preparing the input data and resolving any exceptions
that occur. If the request clearly shows the intent of the writer and it is signed
by the payee, it will be processed in accordance with the instructions in the Direct
Input Preparation Manual. If the intent of the writer is not clear or the request
is not signed by the payee, the modules will send the beneficiary a Form CMS-1763,
Request for Termination of Supplementary Medical Insurance, leaflet SSA-73-10043,
and return envelope under cover of Form SSA-1312, by checking the second block. Type
beneath the form number “If you wish to cancel your medical
insurance, sign and return the enclosed form.” Be sure to complete the top of the Form CMS-1763. If a writing is to be used as a
protective filing date, write “PFD (date) ” in the “Do Not Write in This Space” block.
If any problems are encountered which cannot be handled in the modules, they should
be referred to TOAB.