Form 17 Assistance Center - Frequently Asked Questions

What is Form 17?

Form 17 is a payment authorization form issued by the various HMOs (medical insurers) to their members for treatments, tests and surgeries that are part of the health services basket and performed at institutions outside the HMO. This form is a precondition for the HMO to fund medical treatment. Without this form, the patient will be required to pay the full amount for the service received. As every person in Israel is a member of an HMO by law, the HMO’s refusal to issue a Form 17 may be illegal.

I have an appointment for medical service/treatment at Hillel Yaffe Medical Center, but my HMO is not willing to issue Form 17. What should I do?

You need to check whether your HMO's refusal is legally justified. The Assistance Center will examine this issue after the patient has submitted all the documents required and, to the extent possible, will help you obtain the referral from the HMO.

Please note! There are several fields of medicine in which treatment at Hillel Yaffe Medical Center can be received regardless of where the patient lives: oncology, ER, maternity, gynecological surgery, psychiatric hospitalization.

What forms do I need to send to the Assistance Center so they can examine the request to receive treatment at Hillel Yaffe Medical Center? 

• Medical documents - medical summary containing the referral for treatment, the referral for treatment at Hillel Yaffe Medical Center and a medical summary from Hillel Yaffe (if any). 
• The HMO’s refusal letter. 
• A signed power of attorney. If you are the patient’s legal guardian or legal representative, attach the letter of appointment/relevant documents. 
• Waiver of medical confidentiality.

E-mail the forms to our Assistance Center: [email protected]  

Can a Form 17 be requested from a hospital that is not part of the selection policy?

A member may request Form 17 from their HMO even if the medical center is not part of the selection policy, provided there is medical justification, for one of the following reasons: 

• Availability of appointments at the requested medical center is better than at the medical center suggested by the HMO, depending on medical urgency. 
• Continuity of care - if the HMO member is already being treated at a medical center and the treatment is being funded by the HMO (for example, when the HMO member was treated at the medical center prior to the reform). 
• An HMO member treated at Hillel Yaffe due to their medical condition. 
• Treatment at Hillel Yaffe Medical Center is more appropriate for the patient's condition than treatment at the HMO's facilities or at a different medical center. 
• A medical condition that requires geographic proximity to Hillel Yaffe Medical Center.