Effective Date: 
7/2009

Documents

Instructions

Updated: 7/2009

Purpose

Form H4800 serves as:

  • formal notice that an applicant or client is dissatisfied with an agency action and has requested a fair hearing.
  • documentation of the basis for the appellant's dissatisfaction.
  • notification to the agency that the appellant has an authorized representative or legal counsel and the appellant's authorization to the agency to release relevant information to the representative.
  • notification to hearings officers of the names of individuals outside the program or agency area who are to be notified of the date and time of a hearing.
  • notification that the client or former client is requesting a fair hearing to dispute the existence of an over-issuance claim.

Procedure

When to Prepare

Note: This form should only be used by regions that currently are not creating appeals via the Texas Integrated Eligibility and Redesign System (TIERS) Hearings and Appeals module.

The worker, technician, contract manager, contractor or investigator prepares Form H4800 when an applicant or client wishes to appeal an agency action. The appellant's signature on Form H4800 is not necessary except when the appellant has a representative. If the appellant has a representative and has not signed Form H4800, the person preparing Form H4800 must submit evidence that the authorized representative has the authority to represent the appellant (for example, inquiry screen, guardianship papers, program application).

Staff must ensure that Form H4800 is sent to the hearings officer within five days from the date the request for appeal is received by the agency.

Transmittal and Copies

Send Form H4800 electronically to the appropriate Hearings Division email address in Outlook, in accordance with local appeals procedures.

Hearings staff implement the fair hearing process by sending one copy of Form H4800 to each of the following:

  • the appellant, along with the original Form H4803, Notice of Hearing;
  • the appellant's representative, if appropriate; and
  • individuals outside the program agency area scheduled to participate in the hearing (for example, Office of Attorney General, Texas Workforce Commission).

Form Retention

The hearings officer keeps a copy in the official hearing file. The worker or program representative keeps a copy in the case record file.

Detailed Instructions

To: Hearings Division — Enter the name of the division responsible for the hearing.

Agency Representative's Name — Enter the name of the individual or designee who will serve as the agency representative during the fair hearing. The hearings officer contacts this person if additional information is needed.

Region — Enter the two-digit number of the region that made the appealed decision.

Unit No. — Enter the two-digit number of the unit that made the appealed decision.

Date Sent to Hearings Office — Enter the date Form H4800 is sent to the hearings office.

Date Received by Hearings Office — Leave blank as the date is entered by hearings office staff upon receipt of Form H4800.

Direct Dial Telephone No. for Agency Representative — Include the area code as the hearings officer may call this number.

Method Form H4800 Sent — Check the box that shows the method that Form H4800 is sent to the hearings office by sending it via e-mail to the appropriate Hearings and Appeals mailbox.

Agency Representative's Office — Enter the street address, city, state and ZIP code of the agency representative as the hearings officer uses this address for hearings-related correspondence.

Appellant's Name — Self-explanatory.

Agency Representative's Email Address — Self-explanatory.

Case No. — Enter the case number being appealed. If there is no case number, enter the appellant's Social Security number.

EDG No. — Enter the eligibility determination group (EDG) number for TIERS cases only.

Supervisor's Name — Enter the supervisor's name as it is shown in Outlook.

Supervisor's Area Code and Telephone No. — Self-explanatory.

Appellant's Area Code and Telephone No. — Self-explanatory.

Supervisor's Office Address — Include the mail code, street, city, state and ZIP code.

Appellant's Mailing Address — Enter the street or P.O. Box, apartment number, city, state and ZIP code.

County Name — Self-explanatory.

County Code — Self-explanatory.

Appellant's Residence Address — Enter the street, apartment number, city, state and ZIP code.

County Name — Self-explanatory.

County Code — Self-explanatory.

1. Program — Check the applicable boxes of the programs being appealed. Check Box B if the program being appealed is Supplemental Nutritiion Assistance Program (SNAP) and the issue is related to employment services. Check Box D if the program being appealed is Temporary Assistance for Needy Families (TANF) and the issue is related to employment services.

2. Agency Action Resulting in Hearing Request — Check the boxes that best describe the reason for the hearing request.

  • Application for Assistance Denied — The request to appeal results from a denial of an application for assistance.
  • Assistance Discontinued — The request results from the discontinuance, cancellation or suspension of benefits or services.
  • Benefit Amount — The request results from the
    • determination of the amount and/or form of authorization of a protective payment;
    • protective payee selected to receive and manage the payment for the appellant; and
    • failure to reconsider the need for protective payment.
  • Not Benefit Amount Related — The request to appeal results from other reasons, including:
    • delays in determining eligibility or providing assistance;
    • decisions about participation in employment services;
    • decisions about the amount of medical assistance, a Medicaid claim or the type of medical assistance provided; and
    • regulatory decisions concerning nurse aides.

3. Are benefits/services continued as a direct result of the appeal? — Check Yes or No.

4. Has household specifically waived continued benefits/services? — Check Yes or No.

5. Date the agency was notified of the appeal — Enter the earliest date the appellant expressed dissatisfaction with the action. This may be the date the agency learned of the request or the date correspondence was received, telephone calls, etc., in which the appellant expressed dissatisfaction.

6. How was the agency notified of the appeal request? — Check the box that best describes the medium through which the agency learned of the appellant's request to appeal.

7. a. Date of agency action being appealed: — Enter the date of the agency decision or action that is being appealed.

7. b. Action effective date: — Enter the date the decision or action was or will be effective.

8. Summary of agency action and applicable handbook reference(s) or rules: — Summarize the action that is appealed. Include the appropriate handbook reference(s) or rules that justify the action. Note: Minimize the use of abbreviations.

9. Is an interpreter required? — Check Yes or No if the appellant requires an interpreter. If Yes, specify the language used by the appellant.

10. Does appellant require special accommodations to participate in a hearing? — Check Yes or No. If Yes, explain if the appellant needs a reader, home visit or other needs.

11. List the names, addresses and telephone numbers of additional witnesses/representatives ... — Self-explanatory.

12. Does appellant have a designated representative on the application? — Check Yes or No. If Yes, complete the Name of Representative or Legal Counsel section of the form including the area code, day telephone number and mailing address.

13. Does appellant have a representative not listed on the application? — Check Yes or No. If Yes, complete the Name of Representative or Legal Counsel section of the form including the area code, day telephone number and mailing address.

If the appellant has a representative other than legal counsel and has not signed Form H4800, the person preparing the form must submit evidence that the authorized person has the authority to represent the appellant (for example, inquiry screens, guardianship papers, program application, etc.).

Signature–Appellant and Date — The appellant's signature is not necessary except when the appellant has a representative. Enter the date the form is completed.

Signature–Witness — If appellant signs by X, two signatures of witnesses are required.

 

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