Your LVIM Application

Select “Apply” to begin your LVIM Application.

If you have already completed your application, you may check the status of your application by reviewing any notifications sent about each section of your application. Select “Check Status” below.

Before You Start: What You Need

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

  • Section 1: Initial Patient Information
  • Section 2: Required Document Collection

Before you complete the registration process, it is important to gather the required documentation. The forms you will complete will require you to upload scanned copies of documents.

You will be required to submit:

  • Valid Driver’s License or State ID

Plus, one of the following items:

  • Electric bill in client’s name
  • Current Vehicle Registration
  • Proof of ownership or purchase of homestead property in Polk County
  • Rent receipt for most recent week/month
  • Lease agreement showing current address
  • Recent award letter from state or federal agency

If you do not have any of the above items but live in Polk County, FL,
you will need to Declaration of Domicile form.

You will also need to verify your earnings by submitting:

  • Most recent tax return (if more than two adults)
  • Most recent four consecutive weeks of pay stubs for ALL income earners in the household.

If you do not receive paystubs, you may complete and submit a Verification of Earnings form signed by your employer (s)

  • If self-employed, a Schedule SE is required. If your business is new, expense records are required (bank statements or profit & loss statements)
  • If receiving Social Security benefits or Unemployment compensation, a current award letter is required.

If there is NO income, a Certification of Zero Income form must be completed and submitted.

Optional Forms – As Needed

Depending on your answers on the previous forms, we may require additional documentation to qualify you for our services.