Form H4806, Request for Another Appointment — Request to Withdraw

Effective Date
07/2009
Document
Document
H4806.pdf (120.92 KB)
Document
Document
H4806-S.pdf (122.96 KB)

Instructions

Updated: 7/2009

Purpose

  • To notify the hearings officer that the appellant will be unable to appear for the hearing on the date set.
  • To enable the appellant to request a different time for the hearing from the time the hearings officer has set.
  • To enable the appellant to withdraw their request for a hearing.

Procedure

Number of Copies and Transmittal

The hearings officer mails one copy of Form H4806 to the appellant. It is mailed with Form H4803, Acknowledgment and Notice of Fair Hearing, and an envelope addressed to the hearings officer.

The appellant or the appellant's representative completes Form H4806 and mails it back to the hearings officer if the appellant desires a different hearing date.

The hearings officer determines whether or not a valid reason for postponement exists.

Form Retention

The hearings officer's copy is placed in the case file and retained according to the HHSC Record Retention Schedule.

Detailed Instructions

Blocked in address — Enter the name and mailing address of the appellant.

Date — Enter the date Form H4806 is mailed to the appellant.

Case No. — Enter the appellant's case number.

Hearings Officer — Enter the name of the hearings officer.

Office Address, Area Code and Telephone No. — Self-explanatory.

The rest of the form is completed by the appellant.