Obtain a signed and dated form SSA-521 (Request for Withdrawal of Benefits) or a signed written WD request noting the reason for WD, and determine if the claimant wants to withdraw all benefits (e.g. Retirement Insurance Benefit (RIB) and Medicare) and follow the steps below:

1. 1. 

   Go into the pending claim and annotate the Report of Contact (RPOC) screen in the Modernized Claims System (MCS) (see MS 03508.007) describing the request for WD and include the date the NH signed the request.

2. 2. 

   Annotate approval in the lower portion of the SSA-521.

3. 3. 

   Enter the appropriate code for WD on the Decision Input (DECI) screen (see MS 03509.013) and process the WD request. For withdrawal codes, see SM 00380.040.

4. 4. 

   Fax the signed statement and any related documentation into the Non-Disability Repository for Evidentiary Documents (NDRed).

If the WD request indicates that the applicant wants to withdraw the Title II benefit only (i.e. cash benefits) but retain Medicare then:

• •

  Follow the steps listed above to withdraw the pending claim, and

• •

  Establish the Medicare-only claim in MCS or CCE as follows:

  • –

    Complete the Medicare-only claim with the information the applicant previously provided for the Title II claim (e.g., RIB), including the filing date per GN 00204.007.

  • –

    Enter the signature type and date of the WD request.

  • –

    Award the new claim.

NOTE: If you are unable to obtain the form SSA-521, document the follow up attempts and adjudicate the application as if the claimant had not requested the WD. For follow up procedures, see GN 01010.410C.

SSI applicants and recipients must take all steps necessary to apply for and obtain all possible Title II benefits available. Ensure the claimant understands they must file for and obtain all benefits or SSI eligibility will terminate. Follow the instructions below if the WD request involves SSI:

• •

  Inform the claimant that a WD affects eligibility for SSI; see Overview of the Filing for Other Program Benefits Requirement in SI 00510.001.

• •

  obtain a signed statement on an SSA-795 form (Statement of Claimant or Other Person), clearly stating that the claimant requesting WD of a Title II application is aware of the effect of a WD on SSI eligibility;

• •

  process the WD request following the instructions in subsection A of this section;

• •

  annotate the Report of Contact screen in SSI (see MS 08122.010);

• •

  notify FO personnel who are responsible for administering SSI of the WD request according to local FO procedure; and

• •

  instruct them to take proper action to deny the SSI application or cease eligibility to existing SSI benefits if found eligible for other benefits per SI 00510.001B.6.

An applicant who is potentially eligible for more than one type of benefit (e.g. (RIB) and Disability Insurance Benefits (DIB)) has the option to withdraw the lower benefit payment upon the approval of the second benefit if the applicant filed separate applications. If the applicant is filing simultaneously for both benefits and wants to submit a conditional WD, follow the instructions in GN 00206.055B.1. A conditional WD is different from conversion cases. For information about conversion cases, see GN 00206.055B.1.

• •

  GN 00204.007 Application Filing Date

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  GN 00204.020 Scope of the Application

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  GN 00206.005 Requirements for Withdrawal (WD) of a Benefit Application

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  GN 00206.055 Conditional Withdrawals (WDs)

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  GN 00206.145 Notice of Withdrawal (WD) and Appeal Rights

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  GN 01010.027 District Office Final Authorization (DOFA) Exclusions

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  GN 01010.400 Claim Denials

• •

  SI 00510.001 Overview of the Filing for Other Program Benefits Requirement

• •

  SI 00510.010 Pensions and Certain Compensation Programs as Potential Sources of Other Benefits