Lakeland Volunteers in Medicine will be closed on Friday, July 3rd, in observance of Independence Day. Regular business hours will resume on Monday, July 6th, at 8:00 AM.

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Lakeland Volunteers in Medicine
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Step 1 of 13

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Name(Required)
Please use a unique, accessible email for each household's application. If you are re-enrolling, you may use the same email address that you have used on your household's previous application(s).
Are you the client or are you completing the application on behalf of someone else?(Required)
What is your preferred language?(Required)

If you need assistance completing this application due to a language barrier, please call (863) 688-5846, ext 114.

Si necesita ayuda para completar esta solicitud debido a una barrera del idioma, llame al (863) 688-5846, extensión 114.

Household Information & Family Size

For the purpose of this application, the definition of household includes:
  • The applicant and the applicant's spouse or cohabitating partner (i.e., living together as a couple but not married)
  • Children under the age of 18
  • Student dependents, age 18-21, who are living at home
If there are more than 5 children under 18 or more than 2 student dependents in the household, you cannot enroll online. You must schedule an appointment to complete an application in person by calling (863) 688-5846, extension 104 or 105. Members of the enrollment team are available Monday through Thursday, 8 a.m. to 4 p.m., and Fridays 8 a.m. until noon.

Please fill in the fields below regarding the size and makeup of your household. Include all members of your household whether they are seeking care or not.
There can be no more than 2 adults in the household, and the second adult must be your married spouse or cohabitating partner.
Include all children under the age of 18, whether they are seeking care or not. If there are more than 5 children, you cannot enroll online. Schedule an appointment as explained above.
If the adult dependent in the home is not a student, exclude them from this count.
For the purpose of this application, we are inquiring about adults in the household who are expecting. Exclude Adult Student Dependents who may be expecting from this count.

Adult #1 in Household

Please fill in the fields below with the information of the first adult who is applying to receive care.
Adult #1 Name(Required)
Select the option that best describes Adult #1's LVIM Patient Status.(Required)
New Patient Enrollment & Medical Appointments are Currently Closed New Patient Enrollment & New Patient Medical Appointments are closed for July and August, and will resume in September. If you are a current patient, rescreen appointments are still available. Please call 863-688-5846 EXT 105 to schedule an appointment or reapply online.
Address(Required)
Do you have any form of identification?(Required)
(Driver’s License, Passport (foreign or domestic), State ID, ID card from foreign consulate, etc.) If you do not have an ID, you may still qualify.  Please complete the application and an enrollment screener will contact you.
Max. file size: 300 MB.
Demographic Information
Race (If multi-racial, select multiple.)(Required)
Ethnicity(Required)
Preferred Language(Required)
Marital Status(Required)
Sex(Required)
Proof of Polk County Residency - TWO Proofs are required.
Adult #1: Please select the FIRST Proof of Residency that you will be providing. Only items listed are acceptable.(Required)
You can download the Declaration of Domicile form here.
Drop files here or
Max. file size: 300 MB.
    Max. file size: 300 MB.
    Adult #1: Please select the SECOND Proof of Residency that you will be providing. Only items listed are acceptable.(Required)
    The Rental Verification form is used when an applicant lives or stays with a friend or family member, but has no rental agreement and may or may not pay rent. The purpose of the form is to verify the applicant's physical address. On the form, the friend/family member is the landlord, and the amount of rent paid can be zero.

    You can download the Rental Verification form here.
    Drop files here or
    Max. file size: 300 MB.
      Max. file size: 300 MB.
      Proof of Income
      Adult #1: Select the Proof of Income documentation that you will be providing (select all that apply). Only items listed below are acceptable.(Required)
      Adult #1: If you do not have any of the items listed above, please select all that apply to you below.(Required)
      Drop files here or
      Max. file size: 300 MB.
        Max. file size: 300 MB.
        View & download Verification of Earnings form here.
        Max. file size: 300 MB.
        Max. file size: 300 MB.
        Max. file size: 300 MB.
        Max. file size: 300 MB.
        Drop files here or
        Max. file size: 300 MB.
          Drop files here or
          Max. file size: 300 MB.
            Drop files here or
            Max. file size: 300 MB.
              Because you are currently not earning an income, please complete and upload a Certification of Zero Income form. Be sure to fill out every section of the form. State the date of your last work day where indicated.

              You can download the Certification of Zero income form here.
              Because you are currently not earning an income, please complete and upload a Certification of Zero Income form. Be sure to fill out every section of the form.

              You can download the Certification of Zero income form here.
              IMPORTANT: Be sure to fill out every section on the form.
              Drop files here or
              Max. file size: 300 MB.
                Because you have selected "None of these apply to me," you may not meet LVIM's "working" requirement. However, you should continue to complete this application. After you submit it, this issue will be explored with you through a phone call or an email from an online enrollment screener.

                Adult #2 in Household

                Please fill in the fields below with the information of the second adult in the household who is the married spouse or cohabitating partner of Adult #1, even if they are not seeking services.
                If you do not have an ID, you may still qualify.  Please complete the application and an enrollment coordinator will contact you. 
                Adult #2 Name
                Indicate your relationship with Adult #2.(Required)
                Is Adult #2 seeking care?(Required)
                Does Adult #2 have any form of identification?(Required)
                (Driver’s License, Passport (foreign or domestic), State ID, ID card from foreign consulate, etc.) If Adult #2 is seeking care and does not have an ID, they may still qualify. 
                Max. file size: 300 MB.
                Adult #2 Demographic Information
                Race (If multi-racial, select multiple.)(Required)
                Ethnicity(Required)
                Preferred Language(Required)
                Marital Status(Required)
                Sex(Required)
                Adult #2 Proof of Polk County Residency - TWO Proofs are required.
                Adult #2: Please select the FIRST Proof of Residency that you will be providing. Only items listed are acceptable.(Required)
                You can download the Declaration of Domicile form here.
                Drop files here or
                Max. file size: 300 MB.
                  Max. file size: 300 MB.
                  Adult #2: Please select the SECOND Proof of Residency that you will be providing. Only items listed are acceptable.(Required)
                  Max. file size: 300 MB.
                  The Rental Verification form is used when an applicant lives or stays with a friend or family member, but has no rental agreement and may or may not pay rent. The purpose of the form is to verify the applicant's physical address. On the form, the friend/family member is the landlord, and the amount of rent paid can be zero.

                  You can download the Rental Verification form here.
                  Drop files here or
                  Max. file size: 300 MB.
                    Adult #2 Proof of Income
                    Adult #2: Select the Proof of Income documentation that you will be providing (select all that apply). Only items listed below are acceptable.(Required)
                    Drop files here or
                    Max. file size: 300 MB.
                      Max. file size: 300 MB.
                      View & download Verification of Earnings form here.
                      Max. file size: 300 MB.
                      Max. file size: 300 MB.
                      Max. file size: 300 MB.
                      Max. file size: 300 MB.
                      If Adult #2 does not have any of the items listed above, please select all that apply.(Required)
                      Drop files here or
                      Max. file size: 300 MB.
                        Drop files here or
                        Max. file size: 300 MB.
                          Drop files here or
                          Max. file size: 300 MB.
                            Because Adult #2 is currently not earning an income, please complete and upload a Certification of Zero Income form. Be sure to fill out every section of the form. State the date of your last work day where indicated.

                            You can download the Certification of Zero income form here.
                            Because Adult #2 is currently not earning an income, please complete and upload a Certification of Zero Income form. Be sure to fill out every section of the form.

                            You can download the Certification of Zero income form here.
                            IMPORTANT: Be sure to fill out every section on the form.
                            Drop files here or
                            Max. file size: 300 MB.
                              Because you have selected “None of these apply,” Adult #2 may not meet LVIM’s "working" requirement. However, you should continue to complete this application. After you submit it, this issue will be explored with you through a phone call or an email from an online enrollment screener.

                              Student Dependent (Age 18-21) #1

                              Fill in the fields below for the first adult dependent in the home (student aged 18-21).
                              Student Dependent #1 Name:(Required)
                              MM slash DD slash YYYY
                              Student Dependent #1 Demographic Information
                              Race (If multi-racial, select multiple.)(Required)
                              Ethnicity(Required)
                              Preferred Language(Required)
                              Sex(Required)
                              Is Student Dependent #1 seeking care?(Required)
                              Does Student Dependent #1 have Medicaid?(Required)
                              Are you able to upload Student Dependent #1's Medicaid Card?
                              Max. file size: 300 MB.

                              Student Dependent (Age 18-21) #2

                              Student Dependent #2 Name:(Required)
                              MM slash DD slash YYYY
                              Student Dependent #2 Demographic Information
                              Race (If multi-racial, select multiple.)(Required)
                              Ethnicity(Required)
                              Preferred Language(Required)
                              Sex(Required)
                              Is Student Dependent #2 seeking care?(Required)
                              Does Student Dependent #2 have Medicaid?(Required)
                              Are you able to upload Student Dependent #2's Medicaid Card?
                              Max. file size: 300 MB.

                              Child #1

                              Child #1 Name(Required)
                              MM slash DD slash YYYY
                              Child #1 Demographic Information
                              Race (If multi-racial, select multiple.)(Required)
                              Ethnicity(Required)
                              Preferred Language(Required)
                              Sex(Required)
                              Does Child #1 have Medicaid?(Required)
                              Is Child #1 seeking care?(Required)
                              Are you able to upload Child #1's Medicaid Card?(Required)
                              Max. file size: 300 MB.

                              Child #2

                              Child #2 Name(Required)
                              MM slash DD slash YYYY
                              Child #2 Demographic Information
                              Race (If multi-racial, select multiple.)(Required)
                              Ethnicity(Required)
                              Preferred Language(Required)
                              Sex(Required)
                              Does Child #2 have Medicaid?(Required)
                              Is Child #2 seeking care?(Required)
                              Are you able to upload Child #2's Medicaid Card?(Required)
                              Max. file size: 300 MB.

                              Child #3

                              Child #3 Name(Required)
                              MM slash DD slash YYYY
                              Child #3 Demographic Information
                              Race (If multi-racial, select multiple.)(Required)
                              Ethnicity(Required)
                              Preferred Language(Required)
                              Sex(Required)
                              Does Child #3 have Medicaid?(Required)
                              Is Child #3 seeking care?(Required)
                              Are you able to upload Child #3's Medicaid Card?(Required)
                              Max. file size: 300 MB.

                              Child #4

                              Child #4 Name(Required)
                              MM slash DD slash YYYY
                              Child #4 Demographic Information
                              Race (If multi-racial, select multiple.)(Required)
                              Ethnicity(Required)
                              Preferred Language(Required)
                              Sex(Required)
                              Does Child #4 have Medicaid?(Required)
                              Is Child #4 seeking care?(Required)
                              Are you able to upload Child #4's Medicaid Card?(Required)
                              Max. file size: 300 MB.

                              Child #5

                              Child #5 Name(Required)
                              MM slash DD slash YYYY
                              Child #5 Demographic Information
                              Race (If multi-racial, select multiple.)(Required)
                              Ethnicity(Required)
                              Preferred Language(Required)
                              Sex(Required)
                              Does Child #5 have Medicaid?(Required)
                              Is Child #5 seeking care?(Required)
                              Are you able to upload Child #5's Medicaid Card?(Required)
                              Max. file size: 300 MB.

                              Tax Return

                              While LVIM can still provide you with primary care without a tax return on file, occasionally a partner organization may require a tax return for an ancillary service.

                              Not having a tax return on file may impede the provision of healthcare services that could otherwise be available to you from our partner agencies, including some diagnostics, procedures, and medications.
                              Do you have a tax return from the previous year? (IMPORTANT: A tax return is IRS Form 1040, NOT Form W-2. If you do not have a Form 1040, please select 'No'.)(Required)
                              Max. file size: 300 MB.
                              If you do not have your tax return from the previous year, please explain why.(Required)

                              You have reached the end of the LVIM Application. Please click SUBMIT to ensure your application is saved and submitted to our Enrollment Team.

                              Upon submission, you'll be redirected to a thank you page. Please keep an eye on your email inbox for updates and information regarding your application.

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                              Phone: (863) 688-5846

                              Fax: (863) 802-4640

                              600 W Peachtree St.
                              Lakeland, FL 33815

                              Registered 501(c)(3).

                              EIN: 52-2351630

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                              New Patient Enrollment & Medical Appointments are Currently Closed

                              New Patient Enrollment & New Patient Medical Appointments are closed for July and August, and will resume in September.

                              If you are a current patient, rescreen appointments are still available. Please call 863-688-5846 EXT 105 to schedule an appointment or reapply online.