Form Na 290 - Notice Of Action - Multipurpose
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1
2NOTICE OF ACTION
STATE OF CALIFORNIA
COUNTY OF
HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Notice Date :
Case
Name
:
Number
:
Worker
Name
:
Number
:
Telephone :
Address :
(ADDRESSEE)
Questions? Ask your Worker.
State Hearing: If you think this action is
wrong, you can ask for a hearing. Your
benefits may not be changed if you ask for
a hearing before this action takes place. If
you and the county disagree or if you have
not heard back from your worker, do not
wait to ask for a hearing. You must ask
for the hearing before a certain number of
days. See the back of this notice for more
information and to find out how to ask for
a hearing.
Medi-Cal: This notice DOES NOT change or stop Medi-Cal
Benefits. Keep using your plastic Benefits Identification
Card(s). You will get another notice telling you about any
changes to your health benefits.
CalFresh: This notice DOES NOT stop or change your CalFresh
benefits. You will get a separate notice telling you about any
changes to your CalFresh benefits.
Receiving Medi-Cal and/or CalFresh only DOES NOT count
against your cash aid time limits.
Rules: These rules apply; you may review them at your welfare
office: MPP
Page 1 of ____
NA 290 (2/14) MULTIPURPOSE
REQUIRED FORM - SUBSTITUTE PERMITTED
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Parent category: Legal