Learn about the Medicaid 1115 Transformation Waiver Renewal.
For information about COVID-19, call 2-1-1 and select Option 6.
Find a COVID-19 testing site | COVID-19 vaccine | More COVID-19 information
Downloading a Form to Your Computer
Fillable forms cannot be viewed on mobile or tablet devices. Follow the steps below to download and view the form on a desktop PC or Mac.
- Right Click for PC or Ctrl + Click for Mac on the PDF link and click “Save link as” from the menu.
- Select the folder you want to save the file in and then click "Save."
- Navigate to the folder you saved the file in and Right Click for PC or Ctrl + Click for Mac, then select "Open With" from the menu and select Adobe Acrobat Reader DC.
Note: Open the PDF file from your desktop or Adobe Acrobat Reader DC. Do not click on the downloaded file at the bottom of the browser since it will not open the PDF in Adobe Acrobat Reader DC. It will try to open the file in the browser that results in the same browser error message.
Form 4800-DA, 4800-D Addendum, serves as a document for staff or other program staff to record additional names of other participants to be entered in the Texas Integrated Eligibility Redesign System (TIERS) Fair Hearing system. These are the names of additional staff or individuals outside the program or agency area who are to be notified of the date and time of a hearing.
When to Prepare
The program representative prepares Form 4800-DA in conjunction with Form 4800-D, Fair Hearing Request Summary, when there are more than three other participants who require notification of the date and time of a hearing.
Transmittal and Copies
The program representative sends Form 4800-DA with Form 4800-D to the designated data entry representative (DER) for the program area. For programs with direct access to the TIERS Fair Hearings and Appeals system, the information may be entered directly. Send one copy to the program area supervisor.
Retain a copy of Form 4800-DA for the case record file.
Continue listing other participants from Section 8 of Form 4800-D.
Enter the name of any other participants who are required or have requested to attend the fair hearing. This includes any additional program staff required to attend a hearing.
If the case manager or program representative was not listed as the agency representative, then their name must be listed here.
For each participant listed, enter the name, organization and title. Example: John Smith, case manager.
Enter the participant type for each name. The selection for participant type is:
If the participant will need an interpreter, enter the language.
If the participant will need a special accommodation, enter the accommodation type needed. (Refer to the menu in Item 4A.)
Enter the participant’s mailing address. Include the county and the participant’s area code and telephone number. For agency staff, enter the mail code.
Enter the participant's email address.