Convenio especial de asistencia sanitaria (Comunitat Valenciana)

Special healthcare agreement (Valencian Community)

Official Spanish name on top, English explanation below. Tick each box once you have it; you can show this card at the counter.

Formulario de solicitud (versión vigente)
Application form (current version)
Formulario de domiciliación bancaria, firmado por el titular de la cuenta
Direct-debit form, signed by the account holder