COUNTY OF LOS ANGELES STATE OF CALIFORNIA

080 Long Term Care HEALTH AND WELFARE AGENCY

1500 HUGHES WAY STE B300 DEPARTMENT OF HEALTH SERVICES
LONG BEACH, CA 90810-1808
Date: 05/06/2025
Case Name: WILLIAM KAPOURELOS
Case Number: L4B5930
Worker Name: Customer Service
NOTICE OF ACTION Worker ID: 19DP801O0T
MEDI-CAL Worker Phone Number: (866) 613-3777

WILLIAM J KAPOURELOS
1603 W 36TH PL
LOS ANGELES, CA 90018-4507

Questions? Ask Your Worker

State Hearing: If you think this action is wrong, you can

ask for a hearing. The back page tells you how. Your
benefits may not be changed if you ask for a hearing
before this action takes place. You have only 90 days to
ask for a hearing. The 90 days started the day after the
county sent you this notice.
We reviewed your Renewal to see if you are eligible for the Medicare Savings Programs (Qualified Medicare
Beneficiary [QMB], Specified Low-Income Medicare Beneficiary [SLMB] or Qualifying Individual –1 [QI-1]).

We determined that:

Beginning 06/01/20215, you meet the basic eligibility requirements for the Qualified Medicare Beneficiary [QMB] program.

Benefits are approved for:

WILLIAM J KAPOURELOS

QMB covers Medicare premiums, deductibles and coinsurance fees.

If you have applied for Medi-Cal benefits, you will receive a separate notice about that program.

If you are already receiving Medi-Cal benefits, this does not affect these benefits.

Rules: These rules apply; you may review them at your welfare office:
California Code of Regulations, Title 22, Section(s): 50258,50258.1

CSF 165 (11/2020) 0000000607549110

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California Health & Human Services Agency California Department of Social Services

YOUR HEARING RIGHTS

YOUR HEARING RIGHTS (See also PUB 412 at www.cdss.ca.gov/inforesources/state-hearings )
You can ask for a hearing if you disagree with a county/agency action or failure to act. You have 90 days to do so,
starting the day after the date of the notice. After 90 days, you must prove you had a good reason for asking late. You
can also ask for a hearing to review your benefits for the past 90 days. If you ask for a hearing before the date of the
change, your benefits will continue unchanged. CalFresh will end if you don’t recertify when due.
• Online at acms.dss.ca.gov Click "Create an account" to • Fill out this page, and deliver it by one of the following:
have an ACMS account and get documents online; or click o In-person: Appeals and State Hearings Section
“Submit Appeal without Account” to file without an account 3833 S. Vermont Ave.
4th Floor
OR
Los Angeles, CA 90037
• Call toll free 1-855-795-0634(or TDD 1-800-952-8349) OR
• Fax fill out this page/fax to 1-916-651-2789 OR

o Mail to: CDSS State Hearings Division, PO Box 944243,

MS 21-37 Sacramento CA 94244-2430
o Email to: SHDCSU@DSS.ca.gov
HEARING REQUEST
1. My hearing issue involves (benefit program)
and Los Angeles County/Agency.
2. I want a hearing because:

3. Print name of person who needs a hearing: Birthdate:

4. Mailing Address: Phone number:
I want to get hearing notices from the State Hearing Division by email. Email Address:
5. Name/Signature: Date Signed
6. Interpreter: I want a free interpreter for the language or dialect.
7. Disability Accommodation for hearing? No Yes (explain):
8. Your Hearing will be scheduled by phone. If you want your hearing conducted by a different method, tell us how:
By Telephone By Video (you see judge on your phone/computer) In person at the county hearing site
I have no phone or internet access. I want to go and use the phone or video at hearing site for my hearing.
9. I need a faster scheduled hearing due to Denial of CalWORKs or CalFresh emergency benefits
Medical Emergency Eviction/homelessness Other (explain):
10. If you timely appeal before the action listed in the notice takes place, your aid may stay the same. For CalWORKs
(including Child Care) and CalFresh, if the county action was correct, you have to pay back any extra aid.
Check to have your aid lowered or stopped pending the hearing for: CalWORKs Childcare CalFresh
11. You can have a friend, relative, legal counsel or other person help with your hearing. If they have agreed:
NAME: Email:
Address: Phone:
12. To Get Help: These groups below may be able to give you legal advice or represent you at the hearing:
Legal Aid Foundation of Los Angeles (LAFLA) Welfare Rights Office
(800) 399-4529 4513 E. Compton Blvd.
Neighborhood Legal Services of Los Angeles County (NLSLA) Compton, CA 90221
(800) 433-6251 (310) 603-3341

NA Back 9 (5/22) Required Form - No Substitute Permitted

0000000607549110

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 NOTICE OF ACTION COUNTY OF LOS ANGELES

CSF 165 (11/2020) 0000000607549110

Page 3 of 4
California Health & Human Services Agency California Department of Social Services

YOUR HEARING RIGHTS

YOUR HEARING RIGHTS (See also PUB 412 at www.cdss.ca.gov/inforesources/state-hearings )
You can ask for a hearing if you disagree with a county/agency action or failure to act. You have 90 days to do so,
starting the day after the date of the notice. After 90 days, you must prove you had a good reason for asking late. You
can also ask for a hearing to review your benefits for the past 90 days. If you ask for a hearing before the date of the
change, your benefits will continue unchanged. CalFresh will end if you don’t recertify when due.
• Online at acms.dss.ca.gov Click "Create an account" to • Fill out this page, and deliver it by one of the following:
have an ACMS account and get documents online; or click o In-person: Appeals and State Hearings Section
“Submit Appeal without Account” to file without an account 3833 S. Vermont Ave.
4th Floor
OR
Los Angeles, CA 90037
• Call toll free 1-855-795-0634(or TDD 1-800-952-8349) OR
• Fax fill out this page/fax to 1-916-651-2789 OR

o Mail to: CDSS State Hearings Division, PO Box 944243,

MS 21-37 Sacramento CA 94244-2430
o Email to: SHDCSU@DSS.ca.gov
HEARING REQUEST
1. My hearing issue involves (benefit program)
and Los Angeles County/Agency.
2. I want a hearing because:

3. Print name of person who needs a hearing: Birthdate:

4. Mailing Address: Phone number:
I want to get hearing notices from the State Hearing Division by email. Email Address:
5. Name/Signature: Date Signed
6. Interpreter: I want a free interpreter for the language or dialect.
7. Disability Accommodation for hearing? No Yes (explain):
8. Your Hearing will be scheduled by phone. If you want your hearing conducted by a different method, tell us how:
By Telephone By Video (you see judge on your phone/computer) In person at the county hearing site
I have no phone or internet access. I want to go and use the phone or video at hearing site for my hearing.
9. I need a faster scheduled hearing due to Denial of CalWORKs or CalFresh emergency benefits
Medical Emergency Eviction/homelessness Other (explain):
10. If you timely appeal before the action listed in the notice takes place, your aid may stay the same. For CalWORKs
(including Child Care) and CalFresh, if the county action was correct, you have to pay back any extra aid.
Check to have your aid lowered or stopped pending the hearing for: CalWORKs Childcare CalFresh
11. You can have a friend, relative, legal counsel or other person help with your hearing. If they have agreed:
NAME: Email:
Address: Phone:
12. To Get Help: These groups below may be able to give you legal advice or represent you at the hearing:
Legal Aid Foundation of Los Angeles (LAFLA) Welfare Rights Office
(800) 399-4529 4513 E. Compton Blvd.
Neighborhood Legal Services of Los Angeles County (NLSLA) Compton, CA 90221
(800) 433-6251 (310) 603-3341

NA Back 9 (5/22) Required Form - No Substitute Permitted

0000000607549110

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