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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.
To request changes to an appeal created in the Texas Integrated Eligibility and Redesign System (TIERS) Hearings and Appeals.
When to Prepare
The case manager, technician, contract manager or investigator prepares Form H4800-A to make changes to the appeal created in TIERS Hearings and Appeals.
Number of Copies
Prepare an original Form H4800-A.
Upload the form to the HHSC Benefits Portal.
Email the form to the supervisor.
The original form is filed in the case record.
The record retention for Fair Hearings is based on the HHSC Record/Retention Schedule.
Appeal ID — Enter the appeal ID assigned by TIERS to the appeal.
Appellant's Name — Self-explanatory.
EDG Number (TIERS Only) — Enter the eligibility determination group (EDG) number requiring changes.
1. Hearing Information — Enter the date and time of the hearing as well as the name of the hearings officer assigned to the appeal.
2. Fair Hearing Addendum Details — Provide details on any changes or additions to Form H4800, Fair Hearing Request Summary. Be specific regarding dates, program and issue code.
Completed By and Phone Number — Enter the name and phone number of the person completing the form.
Agency Representative Signature and Date — Sign and enter the date the form is completed.