Health and Dental: Designated Authorized Person

Doctors of BC Health & Dental Plan

Schedule B - Designated Authorized Person
Please use this form to add or change the Designated Authorized Person ("DAP") who is associated with your Business Account for the Doctors of BC Health and Dental Plan.
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
- Authorize new dependants to enrollee's coverage
- Terminate employee coverage
- Authorize bank account changes (if the DAP is also an authorized signatory on the bank account)
- Communicate with Doctors of BC and receive information about employee enrollment
Doctors of BC will accept instructions from either your DAP or you (the Sponsoring Physician).
1. Sponsoring Physician/Employer
Name of Health and Dental Business Account
Found on your health and dental invoice
Business ID, if known
your Business ID is found in the top right of your health and dental invoice
Sponsoring Physician's Email Address

Confirmation EmailReceives copy of request. Please enter email address twice, for accuracy. Addresses must match.
2. Designated Authorized Person
This is a:
Name of Designated Authorized Person

First NameMiddle InitialLast Name
Title of Designated Authorized Person
Email address of Designated Authorized Person

Confirmation EmailThey will receive confirmation that they have been named DAP. Please enter email address twice for accuracy. Entries must match
4. Sponsoring Physician/Employer Signature
It is my responsibility to confirm with Doctors of BC any changes to the authorized Individuals for the corporation/business listed above.

This Schedule B replaces any previously-completed Schedule B.

I will alert Doctors of BC Health & Dental Plan Administrators to any changes to the corporation or clinic name and authorized individuals.
Date

MonthDayYear
Date
Authorized Signature
Sponsoring Physician Name

First NameLast Name
Should be Empty:

Doctors of BC Health & Dental Plan

1. Sponsoring Physician/Employer

2. Designated Authorized Person

4. Sponsoring Physician/Employer Signature