Authorization to Participate in Medical Plan

The following sample Authorization to Participate in Medical Plan letter is nothing fancy, but is nonetheless a great template.

While this one focuses on an employee's authorization to participate in a company's medical plan, it could easily be changed to refer to a company's agreement for a corporate medical plan.

Why struggle with written particulars when we’ve got one completed for you. It’s quick, concise and authorizes eligible applicants for a medical plan. 


As an employee of [name of firm] , I do (do not) wish to participate in the Company's Medical Plan.

[name of firm] is hereby authorized to make the necessary deductions from my earnings or any disability benefit paid to me by the company, for the amount specified in the Group Insurance Schedule.

It is my understanding that I will be eligible to participate in the Company Medical Plan as of [date] and that the monthly deductions referred to herein will begin on [date]

I further understand that the acceptance of my application for participation in the Company Medical Plan is contingent upon my ability to meet the medical requirements determined by [name of insurance company]

Date:_________________ Signature:___________________________

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Authorization Form
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