Form 17 Assistance Center

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 on-line form: https://www.tfaforms.com/5157690  

By email: [email protected]

By phone: *8371

The Assistance Center is open Sunday-Thursday, 8:00 a.m. – 3:00 p.m.

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.

You have the right to receive professional, effective service that is close to home. Do not give up on this right. Contact us today!

Please note!

• Understand that handling your request can take time. 
• If you require urgent medical care, you can independently contact your HMO and/or your doctor and/or the Ministry of Health. 
• For the avoidance of doubt, the medical center does not guarantee it will be able to achieve results with your HMO, but it will do its utmost to help you, all according to the law. 
• As long as your HMO has not issued a undertaking for payment for treatment at Hillel Yaffe Medical Center, Hillel Yaffe Medical Center will not have any obligation in this regard, and if you want, you will need to turn to the appropriate court on your own. 
• In any event, without payment, no treatment will be provided by Hillel Yaffe - the appropriate undertaking for payment from the HMO and/or payment by the patient.