Form 17 ("Tofes Shva Esrei") is a payment voucher or a letter of financial obligation ("Tofes Hitchayvut") from the health plan to the medical service or treatment provider that is given to the policyholder.
The voucher is issued to the policyholder prior to receiving the service or treatment, and serves as an indicator that the health plan has agreed to pay for provision of medical services.
Policyholders for whom a health plan has refused to issue a payment voucher (form 17) are entitled to appeal the decision to the Commissioner.
Issuance of Form 17 requires a deductible payment fee of 30 NIS for all medical services in a given calendar quarter (the amount varies by health plan)

In the event that the policyholder is in need of immediate medical care with a service provider with whom the health fund has entered into an agreement (hospitals, institutes and other service providers who are not part of the plan), they must request from the health plan a payment voucher (Form 17).

  • Health plan policyholders are entitled to choose service providers from among those provided by their health plan or on its behalf, subject to the health plans' choice of service provider arrangements.
  • A payment voucher (Form 17) serves as an indicator of the health plan's obligation to pay a service provider for medical services provided to a policyholder.
  • Obtaining the payment voucher (Form 17) from the health plan is a prerequisite for obtaining payment from the health plan for the necessary medical services.
  • Before receiving medical services, it is always recommended to see if a payment voucher is required and needs to be obtained from the following sources: the referring party; the service provider; the policyholder's primary care clinic.

Target Audience and Prerequisites

  • All health plan policyholders who have a scheduled medical appointment which requires a payment voucher (form 17).

Stages of the Process

  • A policyholder who needs to request a payment voucher (form 17), should go to their local branch of their health fund.
  • One should present a referral from their attending physician or documentation indicating an appointment at the service provider, in addition to relevant medical documentation and their health plan membership card.
  • In certain circumstances, receiving the request requires the special permission of an administrative physician or administrator. Approval in such cases can take up to several days.
  • Form 17, which has been approved, will be given to the policyholder in the health clinic. One can also obtain it through printing it off their personal account on the health fund's website, with a password in which the policyholder was given.
  • Generally, even if the policyholder requires several treatments of the same nature, s/he should request a separate payment voucher for each treatment. One cannot obtain a voucher which commits to payment for all treatments.
  • In the case of a series of identical and prolonged treatments (chemotherapy, rehabilitation, physical therapy, etc.), in accordance with rules set by the health fund, one can receive a single payment voucher for a specified period, and it is advised to check into this option when issuing the form.

Paying the Deductible

  • Obtaining a payment voucher (form 17) requires a co-pay of 30 NIS (the amount can vary from different health funds).
  • Payment for a referral to an outpatient clinic is quarterly (once every three months) - additional visits at the same clinic that quarter will not require an additional fee when one has obtained the payment voucher.
  • Each health fund has an established quarterly payment ceiling for medical services.
  • There are certain populations which are totally exempt from co-payments. For more information, see: Health Plan Fee Exemptions for the Seriously Ill and the Exemptions and Discounts for Health Plan Medical Services portal.

More Information on the Health Plan Websites


Refund when a payment voucher was issued but not used

  • If for some reason the insurance paid for the issuance of a Form 17 and it is not used, please contact the health fund to receive a refund.
  • As of 01/01/2017, health funds are required to proactively issue refunds by returning the payment to the policyholder, or informing the policyholder of their entitlement to a refund and how to obtain the refund.

Please Note

  • The health plans' ability to limit policyholders' choice of service providers (which is sometimes expressed through refusal to issue a payment voucher), is subject to a number of principles, such as maintaining continuity of care, professional opinion(s) of relevant medical specialists, and providing relevant treatment opportunities within a reasonable distance of the policyholder's home. Click here for more information about limitations related to the health plans' arrangements for choice of service providers.
  • It is recommended to retain receipts for the payment voucher for future accounting purposes of quarterly payments, up to the qualified payment ceiling.

Laws and Regulations