• Doctors of BC Health and Dental Plan Health Spending Account Open Enrollment

    October 1, 2026 - January 31, 2027

  • This application will take approximately 15 minutes to complete. Only the Sponsoring Physician may complete and sign for the initial enrolment in the Health Spending Account.

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

    1.Your Business ID and Business Account Name
       (you can find this on your most recent Health and Dental invoice)

    2. Your Employee Class Names, if you are choosing more than one class of HSA benefits for your employees.

    3. The names of all participating Physicians & Medical Office Staff, including their date of birth and provincial health plan coverage status.

  • 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.

  • Account Details

  • I confirm that this Business Account is a corporation (unincorporated business are not permitted to participate in the HSA program).*

  • NOTE: if the Business Account name you provided does not match the Business name on file with the Doctors of BC Health and Dental Plan, we will update your Member agreement to the incorporated business account named above. The DocuSign will have the changes.

    The Health and Dental insurance premiums and the HSA must be funded from the same corporate bank account.

     

  • NOTE: Only incorporated business are eligible to participate in the HSA program. If you are not yet incorporated but plan to 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.

     

  • You are the:

  • Only the Sponsoring Physician is allowed to sign for the initial enrolment in the Health Spending Account.

  • Are you the only plan member in the Manulife Health and Dental Plan under your Business Account? (Spouses and dependants are considered 'dependants' and not 'plan members')
  • Who is insured under the Manulife Health and Dental Plan under your Account?*


  • List of Participating Physicians and Eligible Employees

    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 as the plan member and Optional HSA.

    Eligibility Guidelines for Health and Dental members who want to enrol in the HSA:

    1. A Physician (including yourself) must be a plan member of the Doctors of BC Health and Dental plan and have active health or dental coverage.
    2. A Medical Office Staff member must be a plan member of the Doctors of BC Health and Dental plan and have active health or dental coverage.
    3. Do not list dependants as plan members of the HSA. Spouses (even if they are Physicians) and dependant children who are covered under the plan member's Couple or Family plan are considered "dependants" and not "plan members."
      1. Spouse and dependants covered under the plan member's insured Health and Dental Plan will be automatically added as dependants to the plan member's HSA account. 
      2. Spouse and child dependants will share the HSA plan member's HSA limit and do not receive separate limits.

  • Physicians - Health Spending Account

    HSA account limit

  • Any Physician (including yourself) who wants to enrol in HSA, must be insured under the Manulife Health or Dental insured benefits as the plan member.

    Physicians who are covered as dependants are not eligible for a Physician HSA limit.

  • I want to enrol myself (and all other Participating Physicians) under my Account in the HSA*

  • There is no need to submit an HSA Application form if you only have Physicians participating in the health and dental plan and don't want to enrol Physicians in the HSA. You may close this application.

     

  • 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).

  • Physicians - Health Spending Account

    Physician Information
  • Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Is Physician 1 a primary plan member of Manulife Health or Dental insured benefits (i.e. not a dependant)?*

  • Please remove Physician 1 from Schedule A as you've indicated they are not a plan member of Manulife Health or Dental insured benefits.

  • Is there another participating Physician on your Account?*
  • Physician 2 Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Is Physician 2 a primary plan member of Manulife Health or Dental insured benefits (i.e. not a dependant)? TIP: if this person is listed on your invoice and has premiums allocated to them, they are a plan member. Spouse (even if they are a physician) and Child dependants are NOT plan members.*

  • Please remove Physician 2 from Schedule A as you've indicated they are not a plan member of Manulife Health or Dental insured benefits.

  • Is there another participating Physician on your Account?*
  • Physician 3 Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Is Physician 3 a primary plan member of Manulife Health or Dental insured benefits (i.e. not a dependant)? TIP: if this person is listed on your invoice and has premiums allocated to them, they are a plan member. Spouse (even if they are a physician) and Child dependants are NOT plan members.*

  • Please remove Physician 3 from Schedule A as you've indicated they are not a plan member of Manulife Health or Dental insured benefits.

  • Is there another participating Physician on your Account?*
  • Physician 4 Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Is Physician 4 a primary plan member of Manulife Health or Dental insured benefits (i.e. not a dependant)? TIP: if this person is listed on your invoice and has premiums allocated to them, they are a plan member. Spouse (even if they are a physician) and Child dependants are NOT plan members.*

  • Please remove Physician 4 from Schedule A as you've indicated they are not a plan member of Manulife Health or Dental insured benefits.

  • Is there another participating Physician on your Account?*
  • Physician 5 Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Is Physician 5 a primary plan member of Manulife Health or Dental insured benefits (i.e. not a dependant)? TIP: if this person is listed on your invoice and has premiums allocated to them, they are a plan member. Spouse (even if they are a physician) and Child dependants are NOT plan members.*

  • Please remove Physician 5 from Schedule A as you've indicated they are not a plan member of Manulife Health or Dental insured benefits.

  • Is there another participating Physician on your Account?*
  • Physician 6 Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Is Physician 6 a primary plan member of Manulife Health or Dental insured benefits (i.e. not a dependant)? TIP: if this person is listed on your invoice and has premiums allocated to them, they are a plan member. Spouse (even if they are a physician) and Child dependants are NOT plan members.*

  • Please remove Physician 6 from Schedule A as you've indicated they are not a plan member of Manulife Health or Dental insured benefits.

  • Is there another participating Physician on your Account?*

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

     

  • 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.

     

  • Employees - Health Spending Account

    Employee Classes

  • 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 must be applied consistently to every employee who meets it. A class cannot be created solely to provide a different benefit to a particular individual.

  • 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.

     

  • 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?*

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

  • 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?*

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

  • 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?*

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

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

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

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

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

  • I acknowledge that I have read the Guide to Employee Classes document and my classes are valid and include all participating Medical Office Staff participating in my Account.*

  • Medical Office Staff/Employees - Health Spending Account

    Employee Information
  • Employee 1 Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • HSA Employee Class for Employee 1?*
  • Is Employee 1 a primary plan member of Manulife Health or Dental insured benefits (i.e. not a dependant)? TIP: if this person is listed on your invoice and has premiums allocated to them, they are a plan member. Spouse (even if they are a physician) and Child dependants are NOT plan members.*

  • Please remove Employee 1 from Schedule A as you've indicated they are not a plan member of Manulife Health or Dental insured benefits. This may require you scrolling up and saying No for "Are you enrolling your employees in the HSA?"

  • Employee 2 Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • HSA Employee Class for Employee 2?*
  • Is Employee 2 a primary plan member of Manulife Health or Dental insured benefits (i.e. not a dependant)? TIP: if this person is listed on your invoice and has premiums allocated to them, they are a plan member. Spouse (even if they are a physician) and Child dependants are NOT plan members.*

  • Please remove Employee 2 from Schedule A as you've indicated they are not a plan member of Manulife Health or Dental insured benefits.

  • Employee 3 Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • HSA Employee Class for Employee 3?*
  • Is Employee 3 a primary plan member of Manulife Health or Dental insured benefits (i.e. not a dependant)? TIP: if this person is listed on your invoice and has premiums allocated to them, they are a plan member. Spouse (even if they are a physician) and Child dependants are NOT plan members.*

  • Please remove Employee 3 from Schedule A as you've indicated they are not a plan member of Manulife Health or Dental insured benefits.

  • Employee 4 Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • HSA Employee Class for Employee 4?*
  • Is Employee 4 a primary plan member of Manulife Health or Dental insured benefits (i.e. not a dependant)? TIP: if this person is listed on your invoice and has premiums allocated to them, they are a plan member. Spouse (even if they are a physician) and Child dependants are NOT plan members.*

  • Please remove Employee 4 from Schedule A as you've indicated they are not a plan member of Manulife Health or Dental insured benefits.

  • Employee 5 Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • HSA Employee Class for Employee 5?*
  • Is Employee 5 a primary plan member of Manulife Health or Dental insured benefits (i.e. not a dependant)? TIP: if this person is listed on your invoice and has premiums allocated to them, they are a plan member. Spouse (even if they are a physician) and Child dependants are NOT plan members.*

  • Please remove Employee 5 from Schedule A as you've indicated they are not a plan member of Manulife Health or Dental insured benefits.

  • Employee 6 Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • HSA Employee Class for Employee 6?*
  • Is Employee 6 a primary plan member of Manulife Health or Dental insured benefits (i.e. not a dependant)? TIP: if this person is listed on your invoice and has premiums allocated to them, they are a plan member. Spouse (even if they are a physician) and Child dependants are NOT plan members.*

  • Please remove Employee 6 from Schedule A as you've indicated they are not a plan member of Manulife Health or Dental insured benefits.

  • Employee 7 Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • HSA Employee Class for Employee 7?*
  • Is Employee 7 a primary plan member of Manulife Health or Dental insured benefits (i.e. not a dependant)? TIP: if this person is listed on your invoice and has premiums allocated to them, they are a plan member. Spouse (even if they are a physician) and Child dependants are NOT plan members.*

  • Please remove Employee 7 from Schedule A as you've indicated they are not a plan member of Manulife Health or Dental insured benefits.

  • Employee 8 Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • HSA Employee Class for Employee 8?*
  • Is Employee 8 a primary plan member of Manulife Health or Dental insured benefits (i.e. not a dependant)? TIP: if this person is listed on your invoice and has premiums allocated to them, they are a plan member. Spouse (even if they are a physician) and Child dependants are NOT plan members.*

  • Please remove Employee 8 from Schedule A as you've indicated they are not a plan member of Manulife Health or Dental insured benefits.

  • Employee 9 Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • HSA Employee Class for Employee 9?*
  • Is Employee 9 a primary plan member of Manulife Health or Dental insured benefits (i.e. not a dependant)? TIP: if this person is listed on your invoice and has premiums allocated to them, they are a plan member. Spouse (even if they are a physician) and Child dependants are NOT plan members.*

  • Please remove Employee 9 from Schedule A as you've indicated they are not a plan member of Manulife Health or Dental insured benefits.

  • Employee 10 Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • HSA Employee Class for Employee 10?*
  • Is Employee 10 a primary plan member of Manulife Health or Dental insured benefits (i.e. not a dependant)? TIP: if this person is listed on your invoice and has premiums allocated to them, they are a plan member. Spouse (even if they are a physician) and Child dependants are NOT plan members.*

  • Please remove Employee 10 from Schedule A as you've indicated they are not a plan member of Manulife Health or Dental insured benefits.

  • Employee 11 Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • HSA Employee Class for Employee 11*
  • Is Employee 11 a primary plan member of Manulife Health or Dental insured benefits (i.e. not a dependant)? TIP: if this person is listed on your invoice and has premiums allocated to them, they are a plan member. Spouse (even if they are a physician) and Child dependants are NOT plan members.*

  • Please remove Employee 11 from Schedule A as you've indicated they are not a plan member of Manulife Health or Dental insured benefits.

  • Employee 12 Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • HSA Employee Class for Employee 12?*
  • Is Employee 12 a primary plan member of Manulife Health or Dental insured benefits (i.e. not a dependant)? TIP: if this person is listed on your invoice and has premiums allocated to them, they are a plan member. Spouse (even if they are a physician) and Child dependants are NOT plan members.*

  • Please remove Employee 12 from Schedule A as you've indicated they are not a plan member of Manulife Health or Dental insured benefits.

  • Employee 13 Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • HSA Employee Class for Employee 13*
  • Is Employee 13 a primary plan member of Manulife Health or Dental insured benefits (i.e. not a dependant)? TIP: if this person is listed on your invoice and has premiums allocated to them, they are a plan member. Spouse (even if they are a physician) and Child dependants are NOT plan members.*

  • Please remove Employee 13 from Schedule A as you've indicated they are not a plan member of Manulife Health or Dental insured benefits.

  • Employee 14 Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • HSA Employee Class for Employee 14?*
  • Is Employee 14 a primary plan member of Manulife Health or Dental insured benefits (i.e. not a dependant)? TIP: if this person is listed on your invoice and has premiums allocated to them, they are a plan member. Spouse (even if they are a physician) and Child dependants are NOT plan members.*

  • Please remove Employee 14 from Schedule A as you've indicated they are not a plan member of Manulife Health or Dental insured benefits.

  • Employee 15 Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • HSA Employee Class for Employee 15?*
  • Is Employee 15 a primary plan member of Manulife Health or Dental insured benefits (i.e. not a dependant)? TIP: if this person is listed on your invoice and has premiums allocated to them, they are a plan member. Spouse (even if they are a physician) and Child dependants are NOT plan members.*

  • Please remove Employee 15 from Schedule A as you've indicated they are not a plan member of Manulife Health or Dental insured benefits.

  • 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.

     

  • HSA Enrolment - Additional Dependants

  • 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 or your staff have dependants who are currently waiving coverage under, or were not eligible for, the insured Health and Dental Plan, they may be added to the HSA if they meet the above criteria, regardless of their age.

    All participating Physicians and Medical Office Staff will receive information on how to add additional dependants when their HSA plan becomes effective on January 6, 2027.

     

  • Sponsoring Physician: All dependants currently enrolled in the Manulife Health & Dental insurance benefits will be added to the Health Spending Account as dependants. Do you have any additional dependants you want to add?*
  • HSA Dependant 1 Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Do you have additional HSA dependants to enrol?*
  • HSA Dependant 2 Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Do you have additional HSA dependants to enrol?*
  • HSA Dependant 3 Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Do you have additional HSA dependants to enrol?*
  • HSA Dependant 4 Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Do you have additional HSA dependants to enrol?*

  • If you have more than 4 HSA dependants to enrol, please complete a Request for Change form for the remainder. No evidence of insurability is required to add HSA dependants.

  • Physician Enrollment Acknowledgement

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

    By enrolling in the HSA, I authorize the following:

    myHSA Ltd. (“myHSA”), its agents and service providers, to collect, use and disclose relevant information about me to underwrite, administer and adjudicate 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.

  • Agreement Terms

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

  • The Doctors of BC Health and Dental Plan Member Agreement was updated on October 5, 2026, to include the new HSA program. The updated sections are listed below. The full agreement will be sent to you for review via DocuSign upon submission of this application.

    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, or Health Spending Account (“HSA”) program.

  • 22.    For Eligible Physicians, the annual HSA reimbursement limit (“Account 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.

    23.    For each participating Employee Class, the Account 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 Account Limit for that class is nil.

    24.    If I select the HSA for myself and other Eligible Physicians, I will provide the same Account Limit to everyone within the Physician Class. If I select the HSA for an Employee Class, I will provide the same Account Limit to everyone who meets the criteria for that Employee Class.

    25.    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.

    26.    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.

    27.    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.

    28.    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.

  • 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.

  • Submission Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: