An individual who enrolls in Premium-HI for the Working Disabled may withdraw 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 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.