If an individual requests withdrawal of Premium-HI (or SMI) enrollment, be sure the
individual realizes the consequences of the 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 the individual 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 complete a CMS-1763 (Request for Termination of Premium Hospital
and/or Supplementary Medical Insurance) clearly documenting reasons for making the
request.
NOTE: Undocumented requests will be returned to the FO for further development.