Form H4827, Withdrawal of Appeal Request

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Effective Date
H4827.pdf (129.01 KB)
H4827-S.pdf (129.19 KB)


Updated: 7/2009


  • To provide an alternative to Form H4806, Request for Another Appointment, when the client wants to withdraw their request for a hearing.
  • To provide the appellant another means of withdrawing a stated desire to appeal an agency action.
  • To provide program staff another means of communicating the withdrawal of an appeal request.
  • To provide the hearings officer another means of securing a written withdrawal of an appeal request.


Upon notice from a client who wishes to withdraw an appeal request, program staff or the hearings officer forwards the form to the appellant for completion. Include a business reply envelope with the form.

Client is advised to complete and return the form within 10 days of receipt.

Number of Copies

Complete an original and make one copy.


If client contact occurred with program staff, staff forwards the completed form to the hearings officer. Keep a file copy or place a copy in the program case file.

If client contact occurred with the hearings officer, the hearings officer retains the completed form.

Form Retention

Forms are placed with the official record and retained according to the HHSC Record and Retention Schedule.