TX HHS Form 4800-D. Fair Hearing Request Summary

The TX HHS Form 4800-D, Fair Hearing Request Summary, is a crucial document used to initiate an appeal process for individuals seeking continued benefits or services from the Texas Health and Human Services (HHS) system. This form helps resolve disputes between appellants and the agency regarding Medicaid-related actions.

This summary form requires essential information about the appeal, including the type of action, agency action date, and non-TIERS criteria. It also captures details about the appellant, such as their name, date of birth, social security number, and contact information. Additionally, it inquires about special accommodations needed for the hearing process.

The form is typically used when an individual or their representative wants to request a fair hearing to challenge a Medicaid-related decision made by HHS. It should be completed carefully, as it serves as the foundation for the appeal process. The TX HHS Form 4800-D is an essential tool for appellants seeking to resolve disputes and ensure continued access to vital services.