• Doctors of BC Health and Dental Plan Member Agreement with Trustees

  • This application will take approximately 20 minutes to complete.

    To assist in the completion of your form, please ensure you have the following:

    1. Your banking details - if you have not previously submitted banking details to Doctors of BC, you will need to upload a void cheque or attach a direct deposit authorization form. Corporate accounts will require a certificate of incorporation to be submitted as well

    2. Your preferred coverage tiers (Essential, Enhanced, Premier). Details of these tiers can be found on our website.

    3. For all dependants you are enrolling: Full names, dates of birth and knowledge of provincial medical insurance coverage

    4. For all employees you are enrolling: Full names, dates of birth and knowledge of provincial medical insurance coverage

    5. Contact information for Sponsoring Physician. If you are submitting a change request to change the Sponsoring Physician for an account, you will need to provide email contact information for the current and new Sponsoring Physician.

  • Eligibility and Type of Application

  • To be eligible to participate in the Doctors of BC Health and Dental plan, you must be a Canadian resident, who has submitted the application in a province or territory other than Quebec, and not a resident of Quebec at the time the application is submitted.

    Please contact our team at insurance@doctorsofbc.ca so we may refer you to an alternative provider.
  • I am submitting a:*
  • NOTE: (October 19, 2026) The Change to Existing Account functionality should be working as expected - please let us know if you encounter any errors. 

     

  • I would like to enrol the following under my Health and Dental plan (choose one)
  • Who is currently enrolled under the Health and Dental Account?
  • What is your date of birth?*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Unfortunately, you do not qualify to apply for Health and Dental under the Health Benefits Trust Fund Plan at this time. Physicians must be actively at work and under age 65 in order to apply for new coverage. If you would like Doctors of BC to contact you when you have returned to work, please email us at insurance@doctorsofbc.ca and include your expected return to work date.

     

  • CHANGE TO EXISTING APPLICATION

  • What kind of change are you making?

  • To add/change dependants on your existing health and dental plan (or health spending account), please submit a Request for Change.

    This Member Agreement is only required when structural changes are occuring for the Business Account, not for individual changes to insureds.

  • Change to Corporate Account

  • When did corporate entity incorporate?*
  • Date of Incorporation*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Since you incorporated less than 6 months ago, you are eligible to add the Health Spending Account at this time. Do you want to add the HSA?
  • It is currently the HSA Open Enrolment Period. Do you want to add the Health Spending Account at this time?*

  • The 2026 Open Enrolment period runs until January 31, 2026. If you add the HSA during this time, your HSA benefits will be available January 1, 2027.

  • Please complete the next pages as the corporation.

  • Sponsoring Physician Change


  •
  • What is happening to the previous Sponsoring Physician's Doctors of BC Health and Dental Plan benefits?*

  • This Request to Change can serve as the termination request. Both the previous/current and new Sponsoring Physicians must sign the Change Agreement.

    Please note that terminations are final. If the current Physician wants to rejoin the Doctors of BC Health and Dental Plan, evidence of insurability is required and approval is not guaranteed.

  • If transferring coverage to a new Business Account, please have the current Sponsoring Physician complete a separate Member Agreement as a "Change Application" - "Transfer Physician to different Business Account"

  • Is the new Sponsoring Physician enrolling in the Health and Dental Plan?*
  • Is the new Sponsoring Physician for this Change Request also the Sponsoring Physician under the existing Health and Dental Business Account mentioned in the previous question?*

  • Since the existing Health and Dental Account that currently insures the new Sponsoring Physician is not sponsored by the new Sponsoring Physician of this request, please finish this request to Change Sponsoring Physician and then complete a second Change to Member Agreement requesting "Transfer of Physicians to a different Business Account."

    Example: Sarah Smith is becoming the Sponsoring Physician for XYZ clinic but currently participates in Physician coverage under ABC clinic. If Sarah is NOT the Sponsoring Physician of ABC clinic, then ABC clinic should complete the request to transfer Sarah Smith from ABC clinic to XYZ clinic on a separate request.

    If Sarah is the Sponsoring Physician for ABC clinic, she can complete all of this on one request.

  • Name Change or Changing Business Account Entity Type

  • Please NOTE: If your corporate account was enrolled in the Health Spending Account program, the HSA will end on the 1st of the month following the date you submitted the change request.

  • Transfer Eligible Employees or Physicians to a different Business Account

  • Is the Sponsoring Physician the same for both the Transferring and Receiving Business Accounts?*

  • Is the receiving Business Account already participating in the Doctors of BC Health and Dental Plan?*
  • NEW ACCT I would like to enrol the following under the new Business Account (choose one)*

  • Effects of Change

  • We have prefilled the "usual" responses based on the type of change requested. However, you may still choose a different answer. If you're unsure, please contact insurance@doctorsofbc.ca to confirm whether a section is required.

  • Is a new Enrolment form required for the Sponsoring Physician?*
  • Is the bank account changing as a result of this request?*
  • Are the participants on the account changing as a result of this change?*
  • ARCHIVE - Do you want to add/change a Designated Authorized Person as part of this change?*
  • Are two Sponsoring Physician signatures required on this Request for Change (i.e. previous and new Sponsoring Physician)?*

  • Member Details

  • A note for those submitting changes to existing agreements: The questions in this section are written for new applicants. If you are requesting a change to an existing agreement, please answer the questions based on how you want the account to be set up after your requested changes take effect, including the account name, Sponsoring Physician, address, and account structure (corporate or personal). Where possible, we have prefilled answers from the previous page.

  • Do you want to set up the Health and Dental plan under a corporation or different business name?*
  • Format: (000) 000-0000.

  • NEW APPLICATION - PHYSICIAN ELIGIBILITY DECLARATION

  • Please select which applies to you:*
  • Retirement Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • TRAINING COMPLETION OFFER

    Please answer the following questions to determine whether you are eligible for the special training completion offer.

  • I have, within the last 90 days, completed residency or fellowship training.*
  • I am starting independent practice for the first time in my career OR I have previously practiced medicine for a cumulative total of 12 months or less between periods of residency or fellowship training.*
  • I have not previously participated in the Doctors of BC Health and Dental plan as the sponsoring member*
  • Date you completed residency or fellowship training*
     - -
    2 digit month, 2 digit day, 4 digit year

  • You qualify for the Training Completion Offer.

    You do not need to provide evidence of insurability (if applying for Essential or Enhanced plan tier). A 50% discount will be applied to your Health and Dental premiums for the first 12 months. At the end of the discount period, your premium will change to the full premium.

  • You do not qualify for the Training Completion Offer. Evidence of insurability will be required. Our administrators will send you the medical questionnaire required by Manulife.

  • I understand that evidence of insurability (proof of good health), in the form of a writen questionnaire, for me, my eligible dependents and my employees (if any) will be required.

  • List of Participating Physicians, Eligible Employees, and Employee Classes

    Schedule A

  • Schedule A captures all employees and physicians working at least 20 hours per week for the clinic participating in the Health and Dental Plan and Optional Health Spending Account (HSA). Do not include dependants in this section.

  • Note: This e-application includes a physician enrolment form to enrol yourself. A separate Health and Dental Enrolment Form from each eligible employee and participating physician (other than yourself) is required. Additional information may be required by the Health and Dental Plan Administrator or by the insurance company during the application process; and

  • Physicians

  • You are eligible for the Training Completion Offer, but have selected "Premier" tier. Evidence of Insurability is required for the Premier tier. Evidence of insurability is a written health questionnaire for yourself, your spouse, and your dependants (if applicable).

    In order to qualify for 50% discount, you must complete your evidence of insurability within 8 weeks of submitting this application. 

    If you are declined for the Premier tier, you are guaranteed to enrol on the Enhanced Tier.

  • Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Do you want to add Health and Dental for another participating Physician?*
  • Physician 2 Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • ARCHIVE - Do you want to add cost-plus for Physician 2?*
  • Do you want to add Health and Dental for another participating Physician?*
  • Physician 3 Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • ARCHIVE - Do you want to add cost-plus for Physician 3?*

  • You indicated that not all applicants listed on this application are covered under a Provincial/Territorial healthcare plan. Please do not include the ones that are not covered by a Provincial/Territorial healthcare plan in the e-application.

    You may enrol employees and dependents within 90 days of them gaining coverage under a provincial/Territorial healthcare plan. Contact insurance@doctorsofbc.ca and we can assist with enrolment.

     

  • Physicians - Health Spending Account (HSA)

  • Doctors of BC is launching the Health Spending Account on January 1, 2027. If you enrol in the Health and Dental prior to that date and your insured benefits begin prior to January 1, 2027, please be aware that the HSA will not be available until January 1, 2027.

  • Do you want to add the Health Spending Account (HSA) for Physicians participating on this class (must be incorporated)?*
  • I confirm that this Business Account is a corporation (unincorporated businesses are not permitted to participate in the HSA program)*

  • The HSA limit is the maximum amount you and your dependants, or your staff and their dependants, can claim through the HSA each year. Some HSA providers recommend setting the limit at 10–15% of your T4 income. The maximum HSA limit through Doctors of BC is $25,000. Doctors of BC does not provide tax advice and recommends consulting a tax professional to determine the right limit for your situation.

    Once an HSA limit is set, you may adjust your HSA limit each year during the Annual Options Period (September 1 - October 31).

  • NOTE: All participating Physicians on your account will receive the same health spending account limit.

  • Unincorporated doctors are currently not eligible to enrol in the optional Private Health Spending Plan/Health Spending Account (HSA). 

    If you incorporate in the future, you may enrol in the HSA within 6 months of incorporation, or during the annual Health and Dental Options period. We send out invitations around September each year.

     

  • Important funding information - multiple Physicians

     

    The HSA is funded on a pay-by-claim basis up to the HSA limit you select as the Sponsoring Physician. There is no set-up cost or pre-funding required.

    When you assign an annual HSA limit to a Physician, the full annual amount is available for the Physician to claim during the calendar year. For example, if you provide a Physician with a $5,000 annual HSA limit effective January 1, the Physician may submit eligible claims up to the full $5,000 at any time during that calendar year.

    When an HSA claim is processed, your corporate bank account is charged for the claim amount, plus a 5% administration fee and GST of 5% on the administration fee. For example, if a claim is for $500, the total cost of the claim would be $526.25.

    Please budget for the full annual HSA limit. Although you are charged only as claims are processed, a Physician may use their entire available HSA limit at any time. Please ensure your corporate bank account has sufficient funds to cover the annual HSA limits you have provided to participating Physicians, plus applicable administration fees and GST.

    Physicians have 31 days after the end of the calendar year to submit eligible expenses incurred during the previous calendar year. After this submission period ends, any unused HSA amount from the previous year is forfeited, and the new annual HSA limit applies for the new calendar year.

    Unused HSA amounts do not carry forward from one calendar year to the next.

     

  • Medical Office Staff

  • Note: To comply with employer health and dental insurance rules, each employee is assigned an employee 'class.' A class must be distinct.

    For the insured health and dental plan, only one employee class is recognized.

    For the HSA, an employer may establish more than one employee class. Each class must be based on an objective employment-related characteristic permitted under the plan, and the class definition mut be applied consistently to every employee who meets is. A class cannot be created solely to provide a different benefit to a particular individual.

  • You have selected Premier for 'employee' class. Please note that ALL staff will require evidence of insurability to enrol in this tier of coverage, regardless of when they enrol.

    If an employee is not a late applicant and they are declined for Premier coverage, they will be offered Enhanced coverage tier.
  • I want to enrol Medical Office Staff/Employees in my Account in the HSA program.

  • Important funding information

     

    The HSA is funded on a pay-by-claim basis. You do not fund an employee’s full annual HSA limit in advance.

    When you assign an annual HSA limit to an employee, the full annual amount is available to claim during the calendar year. For example, if you provide an employee with a $500 annual HSA limit effective January 1, the employee may submit eligible claims up to the full $500 at any time during that calendar year.

    When a claim is processed, your corporate bank account is charged for the claim amount, plus a 5% administration fee and GST of 5% on the administration fee. For example, if an employee claims their full $500 annual HSA limit, your total cost would be $526.25.

    Please budget for the full annual HSA limit. Although you are charged only when claims are submitted, an employee may use their entire annual HSA limit at any time. Please ensure your corporate bank account has sufficient funds to cover the full annual HSA limits you have provided to your employees.

    Employees have 31 days after the end of the calendar year to submit eligible expenses from the previous calendar year. After this submission period ends, any unused amount from the previous year is forfeited. A new annual HSA limit applies for the new calendar year.

    Unused HSA amounts do not carry forward from one calendar year to the next.

     

  • HSA - Eligible Employee Classes

  • Are you enrolling ALL full-time employees in the same class of HSA benefits?

  • Doctors of BC generally recommends that you offer HSA to all or none of your employees. However, the HSA program is flexible as you can set up different Eligible Employee Classes. Please ensure you have reviewed the Plan Admin HSA classes guide before continuing.

    If you intend to exclude an Employee Class from HSA benefits, please set up a Class with $0 benefit with the name "ALL OTHER STAFF".

  • Valid Employee Class 1 Check: Can you describe the class without using an employee's name?*
  • Valid Employee Class 1 Check: Is the distinction based on an objective employment characteristic recognized under the plan?*
  • Valid Employee Class 1 Check: Would every employee who meets that definition receive the same HSA benefit?*

  • Employee Class 1 appears to be a valid class. Please continue.

  • Employee Class 1 does not appear to be a valid class. Please reevaluate your criteria and select again.

  • Valid Employee Class 2 Check: Can you describe the class without using an employee's name?*
  • Valid Employee Class 2 Check: Is the distinction based on an objective employment characteristic recognized under the plan?*
  • Valid Employee Class 2 Check: Would every employee who meets that definition receive the same HSA benefit?*

  • Employee Class 2 appears to be a valid class. Please continue.

  • Employee Class 2 does not appear to be a valid class. Please reevaluate your criteria and select again.

  • Valid Employee Class 3 Check: Can you describe the class without using an employee's name?*
  • Valid Employee Class 3 Check: Is the distinction based on an objective employment characteristic recognized under the plan?*
  • Valid Employee Class 3 Check: Would every employee who meets that definition receive the same HSA benefit?*

  • Employee Class 3 appears to be a valid class. Please continue.

  • Employee Class 3 does not appear to be a valid class. Please reevaluate your criteria and select again.

  • Valid Employee Class 4 Check: Can you describe the class without using an employee's name?*
  • Valid Employee Class 4 Check: Is the distinction based on an objective employment characteristic recognized under the plan?*
  • Valid Employee Class 4 Check: Would every employee who meets that definition receive the same HSA benefit?*

  • Employee Class 4 appears to be a valid class. Please continue.

  • Employee Class 4 does not appear to be a valid class. Please reevaluate your criteria and select again.

  • Valid Employee Class 5 Check: Can you describe the class without using an employee's name?*
  • Valid Employee Class 5 Check: Is the distinction based on an objective employment characteristic recognized under the plan?*
  • Valid Employee Class 5 Check: Would every employee who meets that definition receive the same HSA benefit?*

  • Employee Class 5 appears to be a valid class. Please continue.

  • Employee Class 5 does not appear to be a valid class. Please reevaluate your criteria and select again.

  • Medical Office Staff/Employees

    Employee Information
  • Employee 1 Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • HSA Employee Class for Employee 1*
  • Do you want to add Health and Dental for another participating Employee?*
  • Employee 2 Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • HSA Employee Class for Employee 2*
  • ARCHIVE - Do you want to add cost-plus for Employee 2?*
  • Do you want to add Health and Dental for another participating Employee?*
  • Employee 3 Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • HSA Employee Class for Employee 3*
  • ARCHIVE - Do you want to add cost-plus for Employee 3?*
  • Do you want to add Health and Dental for another participating Employee?*
  • Employee 4 Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • HSA Employee Class for Employee 4*
  • ARCHIVE - Do you want to add cost-plus for Employee 4?*
  • Do you want to add Health and Dental for another participating Employee?*
  • Employee 5 Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • HSA Employee Class for Employee 5*
  • ARCHIVE - Do you want to add cost-plus for Employee 5?*
  • Do you want to add Health and Dental for another participating Employee?*
  • Employee 6 Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • HSA Employee Class for Employee 6*
  • ARCHIVE - Do you want to add cost-plus for Employee 6?*

  • You indicated that not all applicants listed on this application are covered under a Provincial/Territorial healthcare plan. Please do not include the ones that are not covered by a Provincial/Territorial healthcare plan in the e-application.

    You may enrol employees and dependents within 90 days of them gaining coverage under a provincial/Territorial healthcare plan. Contact insurance@doctorsofbc.ca and we can assist with enrolment.

     

  • Designated Authorized Person

    Schedule B

  • Doctors of BC will accept signed instructions from you, the Sponsoring Physician, or a Designated Authorized Person you appoint, for certain administrative changes.

    A Designated Authorized Person ("DAP") may:

    • Add new employee coverage
    • Add dependents to enrollee's coverage,
    • Terminate employee coverage
    • Authorize bank account changes (if the DAP is also an authorized signatory on the bank acount);
    • Communicate with Doctors of BC and receive information about employee enrolment, invoices, and bank accounts.

    Doctors of BC will accept instructions from either your DAP or you (the Sponsoring Physician). The Sponsoring Physician may change the DAP at any time by completing a new Schedule B. Only one DAP can be authorized at a time.

  • Do you want to name a Designated Authorized Person ("DAP")?*

  • Direct Debit Authorization Form

    Health and Dental Plan

  •
  • I (we) hereby authorize Doctors of BC as Administrator of the Trust Fund to withdraw my monthly Plan premium directly from my (our) bank account.*
  • Monthly Premium Withdrawal - Bank Account Details*
  • Bank Account information on file with Doctors of BC - Premium Withdrawal*
    Rows
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • ARCHIVE - Cost-Plus Claim deposits - I am enrolling in Cost-Plus for myself*
  • Does this bank account require two signatures?*

  • ARCHIVE - Existing Bank Account information - Cost Plus*
    Rows
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • ARCHIVE - Cost-Plus Claim Deposits - I am enrolling in Cost-Plus for my employees*
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • Physician Enrolment

    • The applicant (and dependants) must be covered under a Provincial Health Care Plan (ie BC MSP) to be eligible to participate in this plan.
    • All applicants must be under age 65 at time of enrolment.
    • Applicants must be actively working at time of enrolment
  • Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Gender*
  • Insurance Plan Tier*
  • Are you enrolling any dependants?*

  • Dependant Information

    Health and Dental Insured Plan

  • An “eligible dependant” is defined as any person who is:

    • Your legal spouse, or a person with whom you have lived for one year and have publicly represented as your spouse.
    • Your unmarried dependent child(ren) under age 22, or under age 25 if a full-time student attending an educational institution recognized by the Canada Revenue Agency (CRA) and entirely dependent on you for financial support.

    Dependant(s) not listed will be subject to proof of good health if they are enrolled at a later date.

  • Who are you enrolling as dependants on this plan?*
  • Spouse Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Child 1 Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Child 2 Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Child 3 Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Child 4 Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Child 5 Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Child 6 Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Are all dependants listed above, covered by a Provincial/Territorial healthcare plan (i.e. BC MSP, OHIP, etc)*

  • You indicated that not all dependants listed on this application are covered under a Provincial/Territorial health care plan. Please remove any dependants who are not covered by a Provincial/Territorial health care plan from this e-application.

    You may enrol dependants within 90 days of them gaining coverage under a provincial/Territorial healthcare plan. Contact insurance@doctorsofbc.ca and we can assist with enrolment.

     

  • Do you have any other dependants ages 22-24 who are full-time students?*
  • Do you have any other dependants ages 22-24 who are full-time students?*

  • Refusal of Benefits

  • Are you and/or your dependants insured under a different group health & dental insurance policy?*
  • Do you want to decline participation in Doctors of BC health and dental benefits for you and/or your dependants because you are insured with another plan?*

  • Complete this section if you wish to refuse Extended Health Care and Dental Care for yourself and/or your dependent(s).

    This will be allowed only if similar benefits are currently in force under your spouse’s group policy.

    If you wish to add this coverage at a later date, statisfactory proof of evidence of insurability health for you and/or your dependent(s) will be required. 

  • I refuse Extended Health and Dental coverage as I and/or my dependent(s) are insured under a different health and dental insurance plan.*
  • Effective Date of Coverage*
     / /
    2 digit month, 2 digit day, 4 digit year

  • Physician Enrolment Acknowledgement

  • I am authorized to disclose information about my spouse and dependants in order to enroll them in the plan

    By enrolling in this Plan, I authorize the following:

    Manufacturers Life Insurance Company (“Manulife”), its agents and service providers, its re-insurers and their service providers to collect, use and disclose relevant information about me to underwrite, administer, and adjudicate claims

    If applicable, myHSA Ltd. ("myHSA"), its agents and service providers to collect, use and disclose relevant information about me to underwrite, administer, and adjudicate HSA claims.

    Doctors of BC (my plan sponsor) to collect, use, and disclose information about me, my spouse, and dependents necessary for enrollment and administering the plan.

    I affirm that myself and/or my dependents are covered by a provincial/territorial health plan

    I have expressly requested to complete the application in English. I acknowledge that pursuant to the language laws in Quebec, Manulife will provide me with a French and English version of my policy and all further documents related to the application and policy will be drawn up in English exclusively.

    I declare the information above is accurate and true.

  • Additional Dependent Information

    Health Spending Account (HSA)

  • Dependants of Physicians and Medical Office Staff enrolled in the Doctors of BC Health and Dental Plan and insured by Manulife will be automatically enrolled as dependants in the HSA. Unlike insured benefits, which have a separate annual limit for each dependant, the HSA has a single annual limit for the entire family.  

    The HSA uses a broader definition of dependants than the definition used under your insured Health and Dental Plan, making it possible for additional dependants to be added to the HSA.

    Under the HSA, an eligible dependant is defined as any person who is:

    • Your legal spouse, or a person with whom you have lived for one year and have publicly represented as your spouse.
    • Related to you by blood or adoption and are:
      • living in the same primary residence; and
      • financially reliant on you.

    If you have dependants for whom you plan to waive insured health and dental benefits, they may be added to the HSA if they meet the above criteria, regardless of their age.

     

  • Do you have any additional dependants that you want to add to the HSA only? (Do not include any dependants already listed above)*
  • HSA Dependant 1 Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Do you have any additional HSA dependants to enrol?*
  • HSA Dependant 2 Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Do you have any additional HSA dependants to enrol?*
  • HSA Dependant 3 Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Do you have any additional HSA dependants to enrol?*
  • HSA Dependant 4 Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Do you have any additional HSA dependants to enrol?*

  • Member Agreement Terms

    Between the Doctors of BC member and The Doctors of BC Health Benefits Trust Fund Trustees (the "Trustees")

  • Definitions

    This agreement uses these definitions:

    1.    “I” or to “me” or to “Member” or to “Employer” means the physician described above, whether an individual, corporation, or partnership. If I am not an employer, “I” or “me” refers to me as a physician who is participating in the Health and Dental Benefits plan;

    2.    The “Administrator” means the Association of Doctors of BC Health Benefits Trust Fund (“HBTF”) that is overseen by the Health Benefits Trustees (“Trustees”).

    3.    “Health and Dental Plan” means the insured group benefits provided through the Health Benefits Trust Fund: (i) for an “Eligible Physician,” extended health care and dental benefits; and (ii) for an Eligible Employee of the Physician (excluding an employee who is a physician), extended health care, dental, life, disability and accident benefits, as applicable.

    4.    “Eligible Employees” has the meaning set out in the Health and Dental Plan Benefits Booklet of the Trust Fund in effect from time to time.

    5.    “Physician” means a person who is practicing or has practiced medicine in the capacity as a licensed physician or who has completed residency or fellowship and intends to practice medicine as a licensed physician.

    6.    “Participating Physicians” or “Eligible Physicians” has the meaning set out in the Health and Dental Plan Benefits Booklet of the HBTF in effect from time to time. Participating Physicians may include me as an enrolee or other physicians participating under my plan as an enrolee.

    7.    “Insurer” means the insurance company designated from time to time to insure some or all benefits under the Health and Dental Plan.

    8.    “HSA Administrator” means the third-party service provider designated by the Trustees from time to time to provide administrative services for the HSA Program.

    9.    “HSA” means the optional private health services plan made available to Participating Physicians and, where selected by the Physician, Eligible employee classes, subject to the applicable program rules and limits.

    10. “Physician Class” means the Eligible Physicians who are participating in the HSA Program and are required under the HSA Program rules to receive the same HSA benefit amount.

    11. “Employee Class” means a category of Eligible Employees grouped according to objective, employment-related criteria permitted under the HSA Program. The class definition must be applied consistently to each Eligible Employee who meets it and cannot be created solely to provide a different benefit to a particular individual.

    12. “HSA Limit” means the annual HSA reimbursement limit that the Employer sets for Participating Physicians or Employee Class(es).

     

     

  • Section I – Doctors of BC Health and Dental Plan

    1. I understand that this is a legal agreement between the Trustees and me. I apply to the Doctors of BC Health Benefits Trust Fund (the “Fund” or “Trust Fund”) to participate in the Health and Dental Plan. This Member Agreement sets out the terms and conditions under which I, as a Physician, may participate in the Health and Dental Plan available through the Fund.
    2. I affirm that I am a Canadian resident and am submitting the application in a province or territory other than Quebec (____________), and I am not a resident of Quebec at the time of application.
    3. The participation of each Eligible Employee and Eligible Physician in the benefit plans offered from time to time by the Fund is effective from the first day of the month coincident with or immediately following receipt and acceptance of this Member Agreement and all other required enrolment forms, or on such later date as is determined by the Trustees. I understand that medical evidence may be required to obtain some benefits, and satisfactory completion of those requirements may be necessary before an Eligible Employee or physician may participate in those benefits.
    4. I understand that:
      1. the Insurer or Administrator may require that 100% of my Eligible Employees who work 20 hours a week or more be enrolled in the Health and Dental Plan;
      2. those Eligible Employees and Eligible Physicians that I have agreed may participate in the Health and Dental Plan, if any, are listed in the “List of Eligible Employees” in Schedule “A”; and
      3. the Trustees may amend the participation and eligibility requirements from time to time.
    5. If I choose the Health and Dental Plan for myself as an Eligible Physician, I may choose to enrol my Eligible Employees in the Health and Dental Plan. I must apply for Health and Dental coverage in order to cover my Eligible Employees or Eligible Physicians; however, I may waive my own participation if I have comparable coverage elsewhere. If I currently do not employ any Eligible Employees, I remain eligible to participate.
    6. I have completed Schedule “A” of this Member Agreement listing the Participating Physician(s), Eligible Employees, and other information required by the Fund to administer the Health and Dental Plan.
  • ARCHIVE - 4. I understand that:*
  • ARCHIVE - I understand that:*

  • 20. I understand that the Plan Summary/Details brochure of the Trust Fund and the Health and Dental Plan Booklet, which may be updated, revised, replaced or supplemented in the future by the Trustees, and the remainder of Section I of this Member Agreement set out other terms and conditions governing my participation in the Health and Dental Plan.

  • Section II – Optional Private Health Services Program (“HSA”)

    This Section II applies only if I elect to participate in the optional private health services program, otherwise referred to as the Health Spending Account (“HSA”) program.

    1. For Eligible Physicians, the annual HSA reimbursement limit (“HSA Limit”) will be the lower of the maximum set by the Plan Sponsor or the amount selected by the Physician in Schedule “A”, subject to the HSA Program rules. The maximum limits are subject to change.
    2. For each participating Employee Class, the HSA Limit will be the amount selected by the Physician in Schedule “A”, subject to the HSA rules. If the HSA has not been selected for an Employee Class, the HSA Limit for that class is nil.
    3. If I select the HSA for myself and other Eligible Physicians, I will provide the same HSA Limit to everyone within the Physician Class. If I select the HSA for an Employee Class, I will provide the same HSA Limit to everyone who meets the criteria for that Employee Class.
    4. If I elect to participate in the HSA, I confirm that I am enrolling my corporation in the HSA and that I meet the applicable eligibility requirements.
    5. I understand that the HSA is administered by the HSA Administrator using the systems and processes established for the HSA and that participation may require me to establish and maintain an account with the HSA Administrator.
    6. I agree to comply with the applicable plan administrator agreement, participant terms, privacy terms and other terms of the HSA Administrator, Administrator, and Trustees that apply to the administration of the HSA and use of its systems or platforms.
    7. I understand that the HSA Administrator may collect additional information directly from me and other HSA participants for enrolment, claim adjudication, reimbursement, account administration and other purposes described in its applicable terms and privacy practices.

  • Section III - General Terms applicable to the Health and Dental Plan and HSA

    Administration and Participant Responsibilities

    1. I agree to comply with the applicable plan or program terms, administrator agreements, participant terms, privacy terms and other requirements of the Administrator, Insurer or HSA Administrator, as applicable to my participation in a Program and use of its systems or platforms.
    2. I understand that the Administrator, Insurer, and HSA Administrator, as applicable, may collect additional information directly from me and other participants for purposes including enrolment, eligibility, claim adjudication, reimbursement, account administration and other purposes described in their applicable terms and privacy practices.
    3. I will promptly notify the Administrator of any changes that may affect eligibility for, or administration of the HSA, including changes to Eligible Physicians, Eligible Employees, Employee Classes, corporate status or other required information, by submitting the applicable forms.
    4. I am aware that upon approval by the Trustees, this Member Agreement will come into effect on the date specified by the Fund through its Administrator, provided this Member Agreement and the Plan application forms are complete. I also understand that to be eligible for some of the benefits, the Insurer and HSA Administrator, if applicable, must also give their approval. I understand the Trustees may terminate this Member Agreement by written notice to me. I agree to continue participation in the Fund and the Health and Dental Benefits Plan and the HSA, if applicable, until such date that the Trustees process a completed termination form (which is to be provided upon request to insurance@doctorsofbc.ca) or the physician is no longer an active member of Doctors of BC.

    Authorization to Collect, Use, Disclose and Exchange Information

    1. I authorize the Administrator to collect, use and disclose to the Insurer and/or Agent, as applicable, personal, employment, corporate and plan or program information reasonably necessary to establish, administer and maintain participation in a Plan or Program. This information may include names, contact information, eligibility and enrolment information, physician or employee class, benefit or reimbursement limits, effective and termination dates, and other information reasonably required for administration.
    2. I confirm that I have the authority to provide the Administrator with the personal information of Eligible Physicians and Eligible Employees identified in Schedule “A” and to authorize its disclosure to the Insurer and/or Agent for the purposes described in this Member Agreement. Where required, I am responsible for obtaining any necessary consent from those individuals.
    3. I authorize the Insurer and HSA Administrator, as applicable, to disclose to the Administrator information reasonably required to administer, reconcile and oversee the applicable Plan or Program. This may include enrolment and participation status, benefit or reimbursement limits, effective and termination dates, fees, funding and reconciliation information, and aggregate claims or other claims-related information where permitted by law, subject to applicable privacy laws and the applicable service provider’s privacy practices.
    4. I understand that the Insurer and HSA Administrator may collect health, dental, receipt and other claims information directly from participants for the purposes of adjudicating and reimbursing claims. Detailed claims or health information will not routinely be disclosed to the Administrator, except where reasonably required for program administration, financial reconciliation, audit, fraud prevention, legal or regulatory requirements, or where otherwise authorized or permitted by law.

    Changes to Administrators and Service Providers

    1. The Trustees may appoint, replace or change the Insurer or HSA Administrator, as applicable, from time to time without requiring a new Member Agreement.
    2. If the Administrator, Insurer or Agent changes, I authorize the Trustees, outgoing service provider and replacement service provider, as applicable, to collect, use and disclose information reasonably necessary to transition, establish, administer and maintain my participation in the applicable Program, subject to applicable privacy laws and contractual requirements.
    3. A change in the Administrator, Insurer or Agent does not, by itself, terminate my participation in the applicable Program or require me to enter into a new Member Agreement.

    Termination and Changes to Participation

    1. Termination of, or changes to, my participation in a Program are subject to this Member Agreement and the applicable plan or program rules and terms.
    2. Termination of or changes to my participation in the HSA Program do not, by themselves, terminate my participation in the Health and Dental Plan. Termination of or changes to my participation in the Health and Dental Plan do not, by themselves, terminate my participation in the HSA Program, except where participation in the Health and Dental Plan is an eligibility requirement of the HSA Program.

  • Submission and Next Steps

  • Please click Submit when you are ready. A Health and Dental administrator will review your application for completeness and send you a DocuSign envelope for your final review and signature.

  • This Change to an Existing Agreement requires two Sponsoring Physician signatures. Both you and the previous/current Sponsoring Physician will receive the DocuSign envelope.

  • Submission Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • ARCHIVE - I would like to enrol the following under my Health and Dental plan (check all that apply):*
  • ARCHIVED**** TRAINING COMPLETION OFFER ELIGIBILITY DECLARATION - PLEASE SELECT ALL THE CONDITIONS THAT APPLY:*
  • Should be Empty: