Employee Medical Freeze Form

EMPLOYEE MEDICAL FREEZE FORM

Use this form to request a temporary freeze of employment status, benefits accrual, and/or position hold for medical reasons. Completion of this form initiates a personnel and benefits review. All information provided will be treated as confidential and used only for administrative and benefits determination purposes consistent with applicable law.

Personal Information

Position Information

Full-time Part-time Other:

Medical Freeze Request Details

Request Type (check all that apply):
Hold position/return to same position
Freeze benefits accruals (vacation, sick leave)
Freeze seniority/tenure accumulation
Payroll suspension (unpaid leave)
Other:

Intermittent Leave Requested: Yes

Medical Certification

Supporting documentation attached: Yes No

Benefits and Payroll Implications

I acknowledge that approval of a medical freeze may affect accrual of paid time off, eligibility for employer-paid benefits, and payroll status. Unless otherwise agreed in writing, employee-paid benefit contributions must continue or be arranged to preserve coverage; otherwise, coverage may lapse and subject to applicable continuation rules. The employer may require periodic status updates and medical recertification. Employees remain responsible for any premium payments required to maintain benefits during the freeze.

Employee acknowledges and agrees to notify Human Resources promptly of any change in anticipated return date. Failure to notify or provide required documentation may result in loss of freeze protections and may be treated as a resignation or termination under applicable policies.

Employee elects to: Continue benefit coverage (employee arranges premiums) Suspend benefit coverage

Authorization and Release

By submitting this form I authorize the employer to obtain medical information from my treating provider(s) as necessary to evaluate this request, and to share relevant medical information with benefits administrators and designated management personnel on a need-to-know basis. I expressly authorize my physician to provide records, clarification, and verification to Human Resources.

Employee authorizes background and employment verification checks as needed to process benefits or leave entitlements where permitted by law: Yes No

Employment History

Provide at least two recent employers

Education

Professional References

Provide three professional references

Legal Disclosures

At-Will Employment Statement: Nothing in this form or any approval of a medical freeze alters the at-will employment relationship. Either the employee or the employer may terminate employment at any time, with or without cause, unless otherwise required by a separate written agreement signed by authorized representatives of the employer.

Equal Opportunity Statement: The employer provides equal employment opportunity and does not discriminate on the basis of protected characteristics. Requests for medical freezes will be considered in accordance with applicable nondiscrimination and accommodation obligations.

Applicant Certification

I certify that the information provided on this form and any attachments is true, complete, and accurate to the best of my knowledge. I understand that knowingly providing false or misleading information may result in disciplinary action, up to and including termination. I authorize release of medical and employment information to the extent reasonably necessary to evaluate and administer this request.

I acknowledge that approval of a medical freeze is an administrative action subject to employer policies and may be revoked or modified if the information provided is incomplete, inaccurate, or if business needs require. I agree to cooperate with reasonable requests for documentation and to provide timely updates on my status.

I authorize the employer to contact previous employers and references as necessary to verify employment history and related information where permitted by law: Yes No

HR Use Only

Decision: Approved Denied

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