TX HHS Form 4800-D. Fair Hearing Request Summary

The TX HHS Form 4800-D, Fair Hearing Request Summary, is a crucial document for individuals appealing Medicaid-related decisions in Texas. This form helps resolve disputes by providing a summary of the appeal process, outlining the necessary information to facilitate a fair hearing.

The form requires specific details about the appeal, including the type of action being appealed, the agency's action date, and the individual's method of appeal request. Additionally, it asks for information about the appellant, such as their name, date of birth, and social security number. The form also inquires about special accommodations or interpreter needs.

This form is typically used by individuals appealing Medicaid-related decisions made by Texas Health and Human Services (HHS) or its contractors. It serves as a summary of the appeal process, ensuring that all necessary information is provided to facilitate a fair hearing. Key points to note include:

• The form is used for appeals related to Medicaid decisions in Texas.
• It requires specific details about the appeal and the appellant.
• Special accommodations or interpreter needs can be requested.