An individual, or proper party on the individual's behalf, can withdraw the enrollment application by requesting withdrawal any time before SMI coverage is effective.

To serve as a withdrawal or termination, there must be an appropriately signed and unequivocal statement that:

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  the individual no longer wishes SMI coverage, or

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  the individual wishes to withdraw or cancel the enrollment request, etc.

This statement should preferably be made on Form CMS-1763 adapted for the purpose, and can be accepted electronically (email or fax) or a signed letter, or by an unequivocal sentence written on one of the prescribed enrollment forms listed in HI 00805.075 signed by (or on behalf of) the individual.

An individual may withdraw an enrollment request any time before SMI coverage becomes effective.

A withdrawal of the enrollment request is also honored if filed after the effective month of SMI coverage but within 2 months after the month the enrollment request was filed.

An individual who enrolls during a GEP may withdraw the enrollment request at any time up to when SMI becomes effective.

When withdrawal of an enrollment request is not filed in time to prevent enrollment, it serves as a request for voluntary termination of SMI coverage, effective (as of 7/87) with the end of the month after the month in which the request is filed, as explained in HI 00820.050.

Whenever an individual wants to withdraw or terminate SMI enrollment, the FO should ensure that the individual realizes the effect of such action (see HI 00820.060).

If an enrollment form is received which is merely answered “no” and signed by a person who has enrolled for SMI, it should not be treated as a withdrawal or termination of SMI enrollment without further development by the FO or PSC that received it. The individual should be promptly contacted for an unequivocal signed statement clarifying the individual's intent.

If withdrawal or termination was intended, it can be considered filed as of the date of receipt of the “no” option form only if the unequivocal statement is submitted within 60 days of such receipt.