FORMS

HEALTH ASSISTANCE S.C.p.A.

Forms available

This page provides all the forms required to access Health Assistance service’s activities and procedures.
The forms available on this site are in PDF format (read the brief explanatory note).

Mutua MBA forms

Mutua Nazionale forms

Cassa MBA forms

Mutua MBA Forms

Direct charge request form

Request for Medical Expenses Refund form

Medical Status Form

Medical Status extra Hospitalization Form

COVID-19 extraordinary guarantee indemnity request form

Check-up Request Form

Delegation of Information Form

Network Access Form

Network’s Membership Request Form

IMPORTANT NOTE: With a view to constantly improving the Network under the agreement, we inform you that the agreement requested will be taken over by the company Health Point S.p.A. – single-member company (with registered office in Via di S. Cornelia 9, 00060 Formello (RM), registered in the Rome Company Register under no.14439951006, equal to tax code and VAT number), part of the Health Italia Group. Furthermore, Health Assistance will continue to carry out the preliminary investigation with regard to direct and indirect practices and to establish, through its Operations Center, the point of connection between clients and affiliated Health Facilities. To this end, we ask you to send the duly completed form to the Network Healthpointitalia mailbox network@healthpointitalia.com

Clearance Request Form

Mutua Nazionale Forms

Direct charge request form

Health Status Module

Extra admission health form

Network access module

Medical expenses reimbursement request form

COVID-19 extraordinary guarantee indemnity request form

Cassa MBA Forms

Direct charge request form

Request for Medical Expenses Refund form

Check-up Request Form

Network Access Form

Clients

Convenzione Ministero dell’Interno dip. PS | Federazione Italiana delle Associazioni Sindacali Notarili | Federazione Middle Management