Form H4800-A, Fair Hearing Request Summary (Addendum)

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Effective Date: 3/2023


Updated: 3/2019


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.

Form Retention

The record retention for Fair Hearings is based on the HHSC Record/Retention Schedule.

Detailed Instructions

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.