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” 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/individual application (please do not complete multiple applications for multiple patients using the same email address)
  • Be able to complete and upload PDFs
  • Gather and/or scan & upload documents (i.e. Drivers license, electric bills, etc)

Downloading and Completing Form PDFs

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

  1. Download & complete the form right in your web browser. (Recommended) 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.)
  2. Download, print, scan & re-upload the form. 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.

Saving Your Files

Prior to beginning your application, gather all required files outlined below and save them to the same location on your device (i.e. “All Photos” on your mobile device, or “Desktop” on your computer).

We recommend naming the files in the following manner:

Examples: John-Smith-DriversLicense.jpg, Jane-Smith-VehicleRegistration.pdf, Thomas-Wilson-DeclarationofDomicile.pdf

Before You Start: Document Checklist

Proof of Residency Documents

To verify your Polk County residency, you will be required to submit one of the following items:

    • Valid Driver’s License or State ID
    • 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 are a renter and do not have any of the above listed items, you may complete and submit the Rental Verification Form.


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

Income Verification Documents
In this section, you will need to verify your household’s earnings by submitting one of the following for every income-earning member of your household:

  • Most recent four consecutive weeks of pay stubs for ALL income earners in the household.
  • If you do not receive paystubs from your employer(s), you may complete and submit a Verification of Earnings form signed by your employer(s).
  • If you are self-employed, a Schedule SE is required. If you are self-employed AND your business is new and you have not yet filed taxes, expense records are required (bank statements or profit & loss statements).
  • If you are receiving Social Security benefits or Unemployment compensation, a current award letter is required.
  • If you earn NO income, a Certification of Zero Income form must be completed and submitted.
  • If you have additional income including (but not limited to) alimony, child support, or dividends from investments, you will be required to submit documentation.


If you file taxes, your most recent return will also need to be submitted.

PLEASE NOTE:  A Certification of Zero Income form must be completed and submitted for every non-incoming earning member of your household who is over 18 years of age.

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 on the very first page of the Enrollment application.

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 in order to get your application approved, schedule your new client orientation, and get your first appointment with a healthcare provider scheduled.

Eligibility Frequently Asked Questions

Before you check your eligibility and get started on your LVIM enrollment application, you may have some questions. We can help!

No. You just need to be a resident of Polk County, FL AND you do need a valid form of identification. A passport or ID from your country of origin is sufficient.

No problem! You can verify your residency by completing the Declaration of Domicile form.

For LVIM eligibility purposes, a household is defined as one or more persons living in one dwelling place who are related by blood, marriage, or law or who share assets.

LVIM can see you for medical services only.

Depending on the levels of your coverage, you may still qualify for LVIM. Please call us to ask about your particular situation. 863.688.LVIM x104

No problem! If your place of work does not provide you with paystubs, you can complete the Verification of Earnings or Certification of Zero Income forms. If you are self-employed, you’ll need to submit your Schedule SE and / or your most recent Profit and Loss Statement.

Working can take many forms. We accept individuals who work in the following ways:

  • A traditional job (receive paystubs)
  • Work for cash
  • Self-employed
  • Caregivers – Mothers/Fathers caring for children; caring for elderly parents; caring for a disabled spouse; providing care in exchange for room and board
  • Full-time students
  • Recently unemployed
  • Persons who are disabled and awaiting approval for disability income
  • Persons receiving Social Security Income as their only source of income
  • Full-time students over the age of 18
  • Residents of partner agencies: Lighthouse Ministries, Salvation Army, Talbot House


  • Wages,
  • tips,
  • salaries from all current employment (Gross Income),
  • including self-employment (income minus expenses)


  • Moneys received from sources other than employment.
  • Alimony,
  • Social Security Benefits,
  • Child Support,
  • Social Security Disability (SSDI),
  • Dividends and Interest,
  • Unemployment compensation
  • Income from Estates/Trusts,
  • VA Benefits,
  • Rental Income,
  • Veteran’s Pension,
  • Pensions and Annuities,
  • Worker’s Compensation (LVIM will not see patients forcovered injuries)

DO NOT INCLUDE: Supplemental Security Income (SSI) Food Stamps Temporary Assistance for Needy Families (TANF)