Follow the interview guides in HI 00820.060 and HI 00820.065. If the enrollee still wants to terminate SMI, ask him or her to complete a CMS-1763.
Verify the SMI Medicare Number with the enrollee's HI card or other document, or with
Write the date of the interview in the space provided in the upper right hand corner
of the CMS-1763. If the date of any earlier written request is material to the effective
date of termination, note this in red in the “date filed” block, and attach the earlier request to the form.
Make sure the enrollee explains why he wishes to terminate SMI in specific, not general,