Before you start

A NIE / TIE (foreigner ID number) — needed for almost every step
Empadronamiento: registration at your Madrid address at the town hall — this gates the public health card
For free public cover: an active Social Security 'alta' (your employer files this when you start work)
For the Digital Nomad and other non-lucrative visas: a private policy already in force at the time of application

Step-by-step

1
Get empadronado at your address
Book a cita at your district office (junta municipal de distrito) and register on the padrón with your rental contract or owner's authorisation plus passport/NIE. You receive a 'volante de empadronamiento'. Without it the system cannot assign you a doctor or card.
In personWho: You (each adult; minors added by a parent)Same day if you get a cita; appointments can be 1-4 weeks outFree
2
Make sure your Social Security alta is active
Your employer registers you with Social Security on day one; confirm via the Import@ss app or seg-social.es. If you are self-employed (autónomo) you register yourself. You can also obtain the 'Documento Acreditativo del Derecho' (DAD) to public healthcare from the INSS, though SERMAS can usually check entitlement electronically.
Via employerWho: Employer files the alta; you confirm and request the DAD if neededAlta is immediate; DAD issued on requestFree
3
Enrol at your centro de salud and get assigned a GP
Go to the health centre for your address with NIE/TIE, volante de empadronamiento and (if requested) the DAD. An administrator assigns your médico de cabecera (family GP) and a paediatrician for any children. You leave with a provisional receipt showing your CIPA code, valid immediately for appointments, tests and pharmacy.
In personWho: YouSame visit; plastic card arrives by post in 2-4 weeksFree
4
Arrange private insurance if you need it (or are required to have it)
Buy a policy from Sanitas, Adeslas or DKV to skip public waiting lists for specialists, or because your visa requires it. Digital Nomad and non-lucrative visa applicants must hold a policy with an insurer authorised in Spain giving full cover with no co-pays ('sin copagos'), no waiting periods ('sin carencias') and no deductibles. Madrid's consulate now rejects travel/international policies for these visas.
OnlineWho: You (often via a broker)Cover can start within 1-3 days; activate before a consulate visa appointmentRoughly €50-100/month under 40; more with age and add-ons

Documents you’ll need

Passport and NIE / TIE
Volante or certificado de empadronamiento (issued within the last 90 days)
Proof of Social Security alta, or the INSS 'DAD' entitlement document
Private health policy certificate (for Digital Nomad / non-lucrative visa applicants)

Things most newcomers don’t know

The public health card has a strict order: empadronamiento, then Social Security alta, then enrol at the centro de salud.

Skip the padrón and you cannot be assigned a doctor at all. Newcomers often try to register at a health centre on arrival and are turned away because the regional system links your record to a registered address first.

Source: Comunidad de Madrid — Tarjeta Sanitaria

You don't have to wait weeks for the plastic card — the provisional CIPA receipt works immediately.

The receipt with your CIPA code, and the 'Tarjeta Sanitaria Virtual' app, carry the same legal validity, so you can book GP visits, get tests and collect prescriptions from day one instead of waiting on the post.

Source: vidaenmadrid.com

For the Digital Nomad Visa, private insurance must have zero co-pay and no waiting periods — and travel policies are rejected.

A cheap travel policy or one with co-pays is a common cause of DNV rejection; the rule is full cover 'sin copagos' from a Spanish-authorised insurer.

Source: Exteriores (Spain MFA) — DNV

If you're resident but not contributing, the 'convenio especial' lets you pay into public healthcare — but only after one year of empadronamiento.

It is the safety-net most people overlook; the one-year wait means you still need private cover for your first year in Spain, and it does not subsidise medication.

Source: Ministerio de Sanidad — convenio especial

Common mistakes to avoid

Assuming your employer's Social Security alta automatically delivers a health card — you still have to empadronar and personally enrol at your centro de salud.
Letting empadronamiento lapse or registering at the wrong district: your assigned health centre and GP follow your padrón address.
Buying a co-pay or travel insurance policy for the Digital Nomad Visa — it will be rejected; the policy must be full-cover, no co-pay, no carencia, from a Spanish-authorised insurer.
Expecting the EHIC/GHIC to cover a move: it only covers medically necessary treatment during a temporary stay, not residence, and never private care or repatriation.