Downloading a Form to Your Computer
Fillable forms cannot be viewed on mobile or tablet devices. Follow the steps below to download and view the form on a desktop PC or Mac.
- Right Click for PC or Ctrl + Click for Mac on the PDF link and click “Save link as” from the menu.
- Select the folder you want to save the file in and then click "Save."
- Navigate to the folder you saved the file in and Right Click for PC or Ctrl + Click for Mac, then select "Open With" from the menu and select Adobe Acrobat Reader DC.
Note: Open the PDF file from your desktop or Adobe Acrobat Reader DC. Do not click on the downloaded file at the bottom of the browser since it will not open the PDF in Adobe Acrobat Reader DC. It will try to open the file in the browser that results in the same browser error message.
If still having trouble viewing or downloading a form, click here.
Form 4807-D serves as:
- A documentation form for staff to record information to be entered in the Texas Integrated Eligibility Redesign System (TIERS) Fair Hearing system in order to notify the Health and Human Services Commission (HHSC) Fair Hearings Division that staff has completed or delayed implementing the hearing decision.
- A record for the case record file of the hearing decision and actions taken by program staff.
When to Prepare
The program representative prepares Form 4807-D in response to receipt of the official hearing decision from the Fair Hearings officer reversing the agency’s decision.
Transmittal and Copies
The program representative prepares an original and two copies and sends the original and one copy to the program representative’s supervisor. One copy is retained in the case record file until the original is returned. The supervisor reviews the form for accuracy, retains one copy and sends the original to the designated data entry representative. The data entry representative enters the information in the TIERS Fair Hearing system and signs and dates the form when completed. The data entry representative sends the original Form 4807-D back to the program representative to file in the case record.
Program Representative/Agency Action
Upon receipt of the official decision from the hearing officer, the program representative who attended the hearing implements the action required within 10 calendar days or provides information on implementation delays. The program representative completes Form 4807-D and sends it with a copy to the supervisor for approval and signature along with the appropriate supporting documentation.
Program Supervisor Action
The supervisor reviews the hearing officer’s decision and action taken by the program representative. If the action is approved, the supervisor:
- ensures that all entries are complete and correct;
- signs the form and enters the date; and
- sends the form to the designated data entry representative to enter into the TIERS system.
Designated Data Entry Representative Action
Upon receipt of Form 4807-D, the data entry representative enters the implementation date into the TIERS system and signs and dates the form. The data entry representative returns the original form to the program representative to be retained as a record of the action.
Retain the original form in the case record file for three years after the case is closed.
To: Data Entry Representative (DER) — Enter the name of the DER who will enter the information into the TIERS Fair Hearings and Appeals system.
From: Program Representative’s Name — Enter the name of the individual or designee who served as the program representative during the fair hearing and is completing the form.
Region — Enter the two-digit number of the region that appealed the decision.
Unit No. — Enter the two-digit number of the unit that appealed the decision.
Date Sent to DER — Enter the date Form 4807-D was sent to the DER.
Date Received by DER — The DER enters the date the Form 4807-D was received.
Appellant’s Name — Self-explanatory.
Appeal ID No. — Enter the appeal ID number that has been assigned on Form 4800-D.
Appellant’s Individual No. —Enter the appellant’s individual identification number. This is the Medicaid number or individual number assigned through TIERS or the Service Authorization System (SAS). This number is the only number used as the identification number for this individual throughout the form. Where the system asks for legacy or EDG number, enter this individual number.
Appellant’s Address — Enter the appellant’s mailing address.
Program Representative — Enter the name of the program representative.
Office Mailing Address—Enter the representative’s office mailing address including the street number, city, state and ZIP code.
Program Representative's Supervisor — Enter the name of the program representative’s supervisor.
Supervisor’s Address — Enter the supervisor’s office mailing address including the street number, city, state and ZIP code.
Section B — Hearing Decision Information
Hearing Officer — Enter the name of the hearing officer who provided the decision.
Decision Date — Enter the date the hearing officer rendered the decision.
Date Decision Received by Local Office — Enter the date of receipt of the official decision from the hearing officer.
Hearing Officer’s Decision — Briefly describe the action to be taken based on the hearing officer’s decision and the date by which the action must take place.
Section C — Implementation Delays
Was action on the fair hearing decision delayed? — If there is a valid reason why the action cannot be completed by the date specified by the hearing officer, check “Yes.” If the action is not delayed, check “No.”
Program — Community Care — This is the only choice for programs..
Type of Assistance (TOA) — Enter the specific program for the appealed action.
Implementation Delay Reason — Check the appropriate box. The only acceptable valid reasons are:
- Beyond Agency Control — Check this box if there are circumstances beyond control, such as fire, flood or other acts of nature.
- Individual Refuses to Cooperate — Check this box if the individual refuses to provide additional required information in order to implement the hearing decision or the client refuses to allow necessary actions to take place.
- Pending Information Needed — Check this box if additional information has been requested and is not received by the action due date.
Delay Begin Date — Enter the date the delay begins, such as the date additional information is requested, if the information is not expected to be returned in time to meet the action due date.
Delay End Date — Enter the date all requested information is received or all appropriate actions completed.
Section D — Implementation Details
Implementation Date — Enter the date the action requested by the hearing officer becomes effective. This date is entered into TIERS as the implementation date.
Type of Implementation — Check the box applicable for the action implemented.
Description — Provide a brief description of the action implemented. (Example: “Family Care reinstated to 20 hours per week”; or “Reinstated the level of nursing services in HCS.”)
Benefit Issue Date — Enter the date benefits are issued/reissued. This should be the same date as the Implementation Date.
Signature — Program Representative/Date — The program representative completing the form signs and dates the form.
Signature'supervisor/Date — The program representative’s supervisor signs and dates the form after reviewing for accuracy and completion.
Signature — Data Entry Representative — The data entry representative signs the form after completion of all required data entry into the TIERS Fair Hearings and Appeals system.
Date Entered into TIERS — The data entry representative enters the date all information was entered in the TIERS Fair Hearings and Appeals system.