Health and Dental - Banking Authorization Form

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this form to change the bank account where the monthly premiums for the Doctors of BC Health and Dental Plan are withdrawn.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?
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" The Member agreement collects banking information so no need to complete this form also.
Name of Health and Dental Sponsoring Physician or Clinic
Your Name

First NameLast Name
Doctors of BC #
Email

Confirmation EmailFill in your email address twice to confirm proper spelling. Both entries must match in order to proceed
Are you the Sponsoring Physician of this plan?
What is your title?
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. HBTF Health and Dental includes both monthly premium as well as Cost-Plus claim withdrawal (if enrolled in Cost-Plus)
2. HBTF 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.
Are you authorizing premium withdrawals from a new bank account or a bank account already on file with Doctors of BC?
New Bank Account:
Upload proof of New Bank Account

void cheque, photo of void cheque, or banking deposit form are acceptable forms of proof.
Cancelof
Upload Certificate of Incorporation

If adding a new corporate account, please also include the certificate of incorporation.
Cancelof
Existing Bank Account:
Do you want to update your HBTF Cost-Plus Claims Deposit Bank Account? ⓘ
Cost-Plus
Is this a new bank account or a bank account already on file with Doctors of BC? ⓘ
New Bank Account:
Void Cheque upload

void cheque, photo of void cheque, or banking deposit form are acceptable
Cancelof
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.
Signature of Sponsoring Physician or Designated Authorized Person
Should be Empty:

Banking Authorization/Change Form

Cost-Plus