The purpose of this form is to confirm, in writing, the appellant’s verbal request to cancel an appeal request and provide him an opportunity to continue with the appeal if he did not want to withdraw.
When to Prepare
This form is generated in TIERS when program staff enters an appeal request in TIERS and then cancel it at the appellant's request before sending the request to the Fair and Fraud Hearings Section. All fields in the form are pre-populated by the TIERS system.
Transmittal and Copies
The original letter is generated by TIERS and sent via batch to the appellant.
The form is retained in the TIERS, Hearings and Appeals, Correspondence, indefinitely. No paper form is retained. If the appellant returns the form to the hearings administrator, it is filed and retained according to the HHSC record retention schedule.
Processing a Returned Form H4811
If a Form H4811 is returned to the hearings administrator, it is processed using the internal H4811 process.