Form 17 Assistance Center

Do you have an appointment with a clinic or for a service at Hillel Yaffe Medical Center and your HMO is refusing to issue a payment authorization form (Form 17)? We're here for you

Receiving services at Hillel Yaffe’s outpatient clinics, institutes and for various surgeries and treatments, which are not done while you are hospitalized, requires a payment authorization form (Form 17) from your HMO. If your HMO is not issuing the form to receive the service from us, contact our Assistance Center. The service is provided free of charge to members of all HMOs.

How can you contact us?

By e-mail: [email protected]

By phone: *8371

Attach the following documents:

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 (can be downloaded below).

What do we do?

The Assistance Center checks if there is legal justification for the HMO's refusal to issue Form 17. If the refusal is not justified, we will contact the HMO and the Ministry of Health on your behalf and try to help.

What we check when you contact us:

Your eligibility to receive the service at Hillel Yaffe by law and the selection of providers reform that entered into effect on September 1, 2023
Whether the clinic, treatment or surgery is part of the health services basket
Whether Hillel Yaffe has unique specialization that other hospitals do not offer
Whether Hillel Yaffe offers better availability for the treatment/clinic/surgery than other hospitals do
Continuity of care - if the HMO member was already a patient at Hillel Yaffe Medical Center before the reform
Whether 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
Whether the patient has a medical condition that requires geographical proximity to Hillel Yaffe.