TX HHS Form H4800-A. Fair Hearing Request Summary (Addendum)

The TX HHS Form H4800-A, Fair Hearing Request Summary (Addendum), is a crucial document for individuals seeking to appeal decisions made by the Texas Health and Human Services (HHS) regarding their healthcare benefits. This form helps resolve disputes by providing a clear summary of the fair hearing request.

This addendum requires the appellant's name, EDG number (TIERS only), and fair hearing information. The instructions emphasize the importance of completing, signing, and uploading the form to the HHSC Benefits Portal, as well as emailing a copy to the assigned hearings officer. This ensures that all relevant parties are aware of the appeal.

The Fair Hearing Request Summary (Addendum) is used in situations where an individual wishes to modify their original fair hearing request or provide additional information supporting their appeal. Key features include providing a reason for the request and including any modifications made to the original summary. By following these instructions, individuals can effectively navigate the appeals process.

• This form is typically used by individuals seeking to appeal decisions regarding healthcare benefits.
• The form requires the appellant's name, EDG number (TIERS only), and fair hearing information.
• Completed forms must be uploaded to the HHSC Benefits Portal and emailed to the assigned hearings officer.