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Effective Date: 
7/2009

Documents

Instructions

Updated: 7/2009

Purpose

To notify the worker of the official decision and action to be taken.

Procedure

When to Prepare

Note: If the hearing was created in TIERS Hearings and Appeals, do not complete this form. Program staff should go into TIERS Hearings and Appeals, Decision Implementation.

The hearings officer completes Section A of Form H4807 after reversing the agency's decision.

The worker completes Section B of Form H4807.

Number of Copies

An original and additional copies as required, including copies for the appellant, appellant's legal counsel, HHSC representative at the hearing, and others as determined. Appeals involving medical help, incapacity or a SNAP employment contractor require additional copies.

Transmittal

Hearing Officer Action

Send paper copies or electronic copies to:

  • the HHSC representative at the hearing;
  • appellant;
  • appellant's legal counsel, if applicable; and
  • other(s) as determined by the hearings officer.

Worker or Other Agency Action

If the agency's decision is reversed or the hearings officer refers to the Final Order for special instructions, the worker:

  • takes the required action,
  • completes Form H4807, and
  • immediately sends an electronic or paper copy of Form H4807 to the supervisor for approval and signature along with appropriate support documentation.

Supervisor Action

The supervisor reviews the action taken by the worker. If the action is approved, the supervisor:

  • ensures that all entries are complete and correct;
  • signs the paper form or approves the electronic form by entering his/her name in the space provided;
  • enters the date;
  • mails or e-mails the form to the hearings officer with a copy to the worker; and
  • ensures that a copy of Form H1020 (if used), Form H1000-A/B, Form H1853 and/or Form H1008 is mailed to the hearings officer. If an electronic Form H4807 is sent to the hearings officer, the supervisor indicates that an electronic Form H4807 was transmitted for this case.

The supervisor must ensure that all necessary entries are completed on Form H4807. Supervisors must also ensure that a copy of Form H1020 (if used), Form H1000-A/B, Form 1853 and/or Form H1008 is attached to the Form H4807 being returned to the hearings officer.

Form Retention

Hearings Officer — Keep the original in a special appeals folder with all forms, exhibits and documentary evidence used in making the decision.Retain in the case file.

Supervisor — Keep a copy for one year for worker evaluation, if needed.

Worker — File the case record copy, which is kept for three years after the case is closed. Exception: For TANF, SNAP and CSS Medical Programs, see the retention requirements in the Texas Works Manager's Guide.

Detailed Instructions

Section ACompleted by the hearings staff

Appellant — Enter the name of the appellant as shown on Form H4800.

Region No. — Enter the number of the region in which the appellant resides.

Case/Client No. — Enter the case or client number.

Hearings Officer/Mail Code — Enter the name and mail code of the hearings officer issuing the decision.

Decision Date — Enter the date of the decision.

Section BCompleted by the worker/technician/supervisor

Was Action on Decision Delayed? — Check Yes if the action on the hearing decision was delayed. Check No if action on the hearing decision was not delayed.

If Yes, enter code — Enter the delay code(s) that applies:

  1. Circumstances beyond HHSC's control, such as fire, flood or other acts of nature. If D is used, the reason must be stated.
  2. Additional information/verification was needed from the appellant and the appellant agreed to cooperate. (Form H1020 was given to the appellant.)
  3. Appellant refused to cooperate in providing additional information/verification.

Date Delay — Enter the month, day and year the delay began. Example: SNAP/TANF date delay is the date Form H1020 was sent to the client. Enter the month, day and year the delay ended (date delay ended is the date the client sent in all requested information) and the worker processed the information.

Date Decision Received by Local Office — Enter the date Form H4807 is received in the office.

Date Form H4807 Mailed to Hearing Officer — Enter the date the supervisor mails the signed Form H4807 back to the hearings office.

Type of Action Taken

For SNAP Cases Only

Check the appropriate box(es), A-F, that indicates the type(s) of action(s)taken to implement the hearing decision. If benefits were issued, enter the date(s) benefits were issued and check the method(s) used to issue the benefits.

Box A — Use this box to enter the date when all restored benefits have been issued.

Note: If the client was given a Form H1020 requesting additional information, and the client provided the information on different dates, then enter the date the final restored benefits were issued.

Box B — Use this box when:

  • the client has elected not to provide verification for one or more of the months covered by the order; and
  • final action has been taken to issue restored benefits for the remaining months for which the client has provided the information/verification, or the client's statement was accepted as best available information.

Enter the date benefits were issued to the client for the last month owed the client.

Box C — Use this box to enter the date all supplemental benefits were issued.

Box D — Use this box to enter the date Form H1000-A/B processing was completed to adjust ongoing benefits.

Box E — Use this box to enter the date Form H1018 or the referral to the recovery unit was completed.

Box F — Use this box when the client is not entitled to any additional benefits. Enter the specific reason. Examples:

  • The client opted to receive continued benefits at the correct level; therefore, no further action is required.
  • The client provided additional information/verification establishing ineligibility for additional benefits.

For TANF Cases Only

Check the appropriate box(es), G-L, that indicates the type(s) of action(s) taken to implement the hearing decision. If benefits were issued,

  • enter the date(s) benefits were issued, and
  • check the method(s) used to issue the benefits.

Box G — Use this box to enter the date when all restored benefits have been issued.

Note: If the client was given a Form H1020 requesting additional information and the client provided the information on different dates, enter the date the final restored benefits were issued.

Box H — Use this box when

  • the client has elected not to provide verification for one or more of the months covered by the order; and
  • final action has been taken to issue restored benefits for the remaining months for which the client has provided the information/verification, or the client's statement was accepted as best available information.

Enter the date restored benefits were issued for the last months owed the client.

Box I — Use this box to enter the date all supplemental benefits were issued.

Box J — Use this box to enter the date Form H1000-A/B processing was completed to adjust ongoing benefits.

Box K — Use this box to enter the date that Form H1018 or the referral to the recovery unit was completed.

Box L — Use this box when the client is not entitled to any additional benefits and enter the specific reason. Examples:

  • The client opted to receive continued benefits at the correct level; therefore, no further action is required.
  • The client provided additional information/verification establishing ineligibility for additional benefits.

FOR ALL OTHER PROGRAMS:

Program(s) — Enter the name or acronym of the other program(s).

Check the box that applies to the action taken on any of HHSC's other programs and enter the date of the action, if appropriate.

Worker's Signature/Date — The worker signs and dates Form H4807 when all action has been completed and benefits due have been issued, and sends the form to the supervisor for review and approval.

Supervisor's Signature/Date — The supervisor signs and dates Form H4807 and forwards it to the hearings officer along with any available supporting documentation.