Since incorporated in 1890 Medical Lake has had a Mayor/Council form of government.

In this form of government, the Mayor is given almost total administrative authority, with the power to appoint and dismiss department heads without City Council approval and little public input. The Mayor also prepares and administers the budget, although that budget must be approved by the Council.

Medical Lake has a seven-member City Council which sets policy, often by adopting ordinances(laws), plans, resolutions, and standards.

The City Administrator, the Chief Executive Officer for the City, is appointed by the mayor and confirmed by the City Council. The City Administrator supervises department heads, manages the budget, and coordinates departments.