Form Na 217 - Notice Of Action - Diversion
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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. The back of this page tells how. Your
benefits may not be changed if you ask for a hearing
before this action takes place.
Diversion Payment/Service(s) . . . . . . . . . . . . . . . . . . . . . . $ __________
Maximum Aid Payment __________Person(s)
(Assistance Unit only) . . . . . . . . . . . . . . . . . . . . . . . . . . . . ÷ __________
Diversion Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . = __________
Medi-Cal: This Notice of Action does NOT change or stop Medi-Cal
benefits. Keep your plastic Benefits Identification Card(s).
Rules: These rules apply; you may review them at your welfare
office: MPP
Page 1 of ____
NA 217 (7/99) DIVERSION
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Parent category: Legal