TN 31 (06-04)
HI 00801.145 Withdrawal of Application for Enrollment
An individual who enrolls in Premium-HI for the Aged may withdraw his/her enrollment application without incurring any premium liability by filing a written request for withdrawal at any time within 3 months after notice of HI coverage.
If a request for withdrawal if received more than 3 months after the notice, process as a voluntary request for termination.
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.