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- To record an appellant's request to leave the fair hearing record open after a hearing.
- To authorize the HHSC hearing officer to leave the fair hearing record open for a specific period of time after a hearing.
- To record the number of days and the specific dates that the fair hearing decision may be delayed when the fair hearing record remains open after a hearing.
- To record the reason that the fair hearing record is left open after a hearing.
- To explain the effect of leaving the fair hearing record open after a hearing.
When to Prepare
Complete Form H4804 when an appellant or representative requests that the fair hearing record be left open for a specific period of time after a fair hearing.
Number of Copies
The hearing officer completes and obtains the client's or representative's signature on an original of the form during the fair hearing process.
The hearing officer keeps the original form in the official fair hearing file with Form H4807, Record of Fair Hearing.
The form remains in the official fair hearing file with Form H4807 for three years.
Fill in the name of the appellant or representative requesting that the fair hearing record be left open after the hearing.
Enter the number of calendar days that the appellant or representative requests that the fair hearing record be left open after the hearing.
Enter the reason for the request to leave the record open.
Enter the beginning and ending dates that the fair hearing record will remain open after the hearing.
Signature and date lines — The appellant or representative and the hearing officer sign their names and enter the signature dates on the designated lines.
Name — Enter the name of the appellant.
Case Number — Enter the appellant's case number.
Hearing Officer — Enter the name of the hearing officer who grants the request to leave the hearing record open after the hearing.
Hearing date — Enter the date the appellant's hearing is held.