If an individual requests withdrawal of Premium-HI (or SMI) enrollment, be sure the
individual realizes the consequences of his/her action by following the guidelines
in HI 00805.080 and HI 00820.045 - HI 00820.075 on SMI withdrawal and termination requests. Also, make sure the individual is aware
of the QDWI provisions if he/she is requesting withdrawal because of inability to
If, after receiving a full explanation of the consequences of withdrawal, the individual
still wishes to withdraw, have him/her complete a CMS-1763 (Request for Termination
of Premium Hospital and/or Supplementary Medical Insurance) clearly documenting his/her
reasons for making the request.
NOTE: Undocumented requests will be returned to the FO for further development.