TN 26 (11-93)
HI 00801.174 Withdrawal of Enrollment
An individual who enrolls in Premium-HI for the Working Disabled may withdraw his/her enrollment without incurring any premium liability by filing a written request for withdrawal at any time within 3 months after notice of HI coverage.
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 pay premiums.
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.