When an individual requests withdrawal of Premium-HI enrollment, be sure that the
individual realizes the consequences of his/her 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 he/she is 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, have him/her complete a form CMS-1763 (Request for Termination
of Premium Hospital Insurance and/or Supplementary Medical Insurance), clearly documenting
his/her reasons for making the request.