• Banking Authorization/Change Form

    Monthly withdrawal for Health and Dental Plan premiums

  • INSTRUCTIONS: The Sponsoring Physician or Designated Authorized Person should be completing this form to change the bank account where the monthly premiums for the Doctors of BC Health and Dental Plan are withdrawn.

  • Why do you want to change banking for your health and dental plan?*
  • Have you recently changed your Business Account name (i.e. through a CHANGE to Existing Agreement or HSA Open Enrolment?)

  • For this type of request, we also require a new Member Agreement to be signed as the Sponsoring Physician Business Account name will be changing.

    Please use the Member Agreement link to complete your request. Choose "Change to an existing agreement" and select the appropriate option.

    The Member agreement collects banking information as part of the change, so there is no need to complete this form.


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  • Are you the Sponsoring Physician of this plan?*

  • I/We hereby authorize Doctors of BC to withdraw the premiums for the programs indicated below from the bank account(s) designated on this form, and if applicable, I/we authorize the change of my/our existing bank account records with the new information provided on this form. 

    For information related to privacy of the information collected, please see Doctors of BC Privacy Policy.  

  • Select account for which you are authorizing Direct Debit

  • NOTES:

    1. Health and Dental includes both monthly premium as well as Cost-Plus claim withdrawal (if enrolled in Cost-Plus, which is ending December 31, 2026)
    2. Health and Dental may also include life and accidental death premiums if it is part of your HBTF plan (applies to all eligible employees and physicians enrolled prior to 2014).  If this is the case, do not select AD&D and Life insurance - they will be updated as part of the HBTF banking update
    3. If you are choosing Corporate Account, please include certificate of incorporation, unless you have already submitted to Doctors of BC.
  • Are you authorizing premium withdrawals from a new bank account or a bank account already on file with Doctors of BC?*
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  • New Bank Account:*
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  • Existing Bank Account:*
  • Do you want to update your Doctors of BC Cost-Plus Claims Deposit Bank Account? ⓘ*

  • Cost-Plus

    (please note that Cost-Plus program is ending December 31, 2026)
  • Is this a new bank account or a bank account already on file with Doctors of BC? ⓘ*
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  • New Bank Account:*
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  • Existing Bank Account:*

  • I/We hereby authorize Doctors of BC to deposit the the Cost Plus Claims to the bank account designated above, and if applicable, I/we authorize the change of my/our existing bank account records with the new information provided on this form. 

    For information related to privacy of the information collected, please see Doctors of BC Privacy Policy.  

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