Before You Start: What you need to know

Use the “Document Checklist” to gather all necessary documents prior to beginning.

Important: If you have not already done so, please check to see if you’re eligible to receive LVIM services.

Once you confirm that you’re eligible and have reviewed all important information below, select “Apply Now” to begin your LVIM Application.

There are two sections of the application that must be completed before it is reviewed:

  • Section 1: Initial Patient Information – Answer questions about your household, residence, and income
  • Section 2: Required Document Collection – Gather and upload documentation to provide proof of Polk County residence and your household’s income

In order to complete the application, you must:

  • Have access to an email address unique to your household application
  • Be able to complete and upload PDFs
  • Gather and/or scan & upload documents (i.e. Drivers license, electric bills, etc)

Before You Start: Document Checklist

Identification

If you have any form of identification, you will be asked to upload it to the application. LVIM accepts the following as identification:

  • Driver’s License
  • State ID
  • Passport – foreign or domestic
  • ID card issued by foreign consulate

Proof of Polk County Address

Clients must submit two proofs of Polk County residency. However, one proof may be a current Florida Driver’s License or Florida state ID reflecting the correct and current Polk County address. Please note that ALL documents MUST be in the client’s name and show the client’s current Polk County address.

Clients must upload one of the following items:

  1. Current Florida Driver’s License or State ID with correct address
  2. Electric bill in client’s name
  3. Current Vehicle Registration in client’s name
  4. Proof of ownership or purchase of homestead property in Polk County
  5. Rent receipt for most recent week/month
  6. Lease agreement showing current address and client’s name
  7. Recent award letter from state or federal agency
  8. *If the client is a renter and does not have any of the above listed items, a Rental Verification Form may be submitted.
  9. *If the client cannot provide any of these documents, a Declaration of Domicile Form must be completed and submitted.

For secondary documents, client may submit any document from the above list OR one of the following:

  1. Voter’s Registration
  2. Paystubs with current address
  3. Proof of children registered in Polk County schools
  4. Verification from Polk County probation officer
  5. Verification of homeless status
  6. Letter from a residential program or institute (e.g. Talbot House, Lighthouse Ministries, Salvation Army, Gospel Village, etc.)

Proof of Income

Clients must provide income documentation for ALL income earners in the household. The following items are accepted as proof of income:

  • Four most recent weeks of paystubs
  • Schedule SE, if self-employed this document is required. If self-employed and business is new, must provide expense records (bank statements or profit & loss statements)
  • Social Security award letter if applicable.
  • Unemployment award letter if applicable.
  • If there is no income, a Certification of Zero Income form must be completed and submitted. If spouse/partner is not working and is seeking to become an LVIM patient, they will need to complete this form.

Downloading and Completing Form PDFs

There are two options for completing and uploading the required documentation:

Each of the forms linked below are digital and can be completed right within your browser window. Simply click the form link, and it will open in a new tab. Inside the tab, you can click each form field and type the necessary information. Save the PDF as a new file, and select that file when completing the digital registration form.

(If a signature is required on the forms, you can provide that in your New Patient Orientation if necessary.)

Click the link to download each form and choose print. Once printed, complete the form in it’s entirety, scan and save the completed form, and select the file when completing the digital registration form.

Are you already an LVIM patient?

LVIM clients are required to re-enroll every 12 months in order to re-qualify. If you are already an LVIM client, please select “Existing Client” when asked if you are a new client or an existing client in the Enrollment application.

Apply Now

After You Apply

Following the successful submission of your application, an LVIM Enrollment Coordinator will contact you via an email support ticket to let you know your application is under review.

Once the support ticket is opened, your Enrollment Coordinator will correspond with you via email to alert you of any issues with your application including:

  • Missing documents
  • Incorrect documents
  • Clarifying information needed
  • Incorrect data submitted
  • Eligibility issues

Please be sure the email you use to submit your application is easily and readily accessible so you can communicate with our team.

Your Enrollment Coordinator will help you complete any additional documents required to get your application approved, schedule your new client orientation, and schedule your first appointment with a healthcare provider.