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Lakeland Volunteers in Medicine
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Step 1 of 3

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Name
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 a new or an existing LVIM client?
What is your preferred language?

If you need assistance completing this application due to a language barrier, please call (863) 688-5846, ext 104 or 105.
Fill in the form fields below with the information of the adult client who is applying to receive care.

Applicant Information

Applicant Name
Address

Family Size

Please fill in the form fields below regarding the size and makeup of your household.
Please provide a number of the adults (18+) in the household here.
Are any adults in the household full-time students?
Are there children (under 18 years of age) in the household?
Are any children uninsured and seeking to receive care at LVIM?
Is anyone in the household pregnant?
Required Documents

In the form below, you will submit the required documentation to 1) verify you are a Polk County resident and 2) verify your income. 

Proof of Polk County, FL Residency

In addition to an ID, clients must submit at least one other proof of residency. Clients may upload one of the following items:
  1. Electric bill in client’s name

  2. Current Vehicle Registration in client's name

  3. Proof of ownership or purchase of homestead property in Polk County

  4. Rent receipt for most recent week/month

  5. Lease agreement showing current address and client's name

  6. Recent award letter from state or federal agency

ALL documents MUST be in the client's name and show the client's current Polk County address.
*If the client is a renter and does not have any of the above listed items, complete and submit the Rental Verification Form.
*If the client can not provide any of these documents, a Declaration of Domicile form must be completed and submitted.
A Driver's License/Photo ID and one additional proof of residency documentation (as listed above) must be submitted for each adult (18+) in the household seeking care. Multiple files can be uploaded in the form fields below.
Do you have a Florida ID?
Is your ID a Polk County, Florida ID?
(You may select & upload multiple files)
Drop files here or
Max. file size: 300 MB.
    Do you have another form of photo ID (out-of-state ID, foreign or domestic passport, ID from a foreign consulate, etc)?
    (You may select & upload multiple files)
    Drop files here or
    Max. file size: 300 MB.
      Please select the additional proof of residency that you will be providing.
      (If you are uploading more than document, you can make multiple selections)
      Please select the 2 additional proof of residency that you will be providing.
      (As a resident outside of Polk County, FL, you're required to upload 2 additional proof of residency)
      You can download the Rental Verification form here and the Declaration of Domicile form here.
      Drop files here or
      Max. file size: 300 MB.
        (You may select & upload multiple files)
        Drop files here or
        Max. file size: 300 MB.
          (You may select & upload multiple files)
          Drop files here or
          Max. file size: 300 MB.

            Proof of Income

            Clients must provide income documentation for ALL income earners of the household.

            Along with pay stubs, the client can upload any of the following on behalf of all income-earners in the household.

            • Tax Return
            • 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, they will need to complete this form
            Multiple files can be uploaded in the form fields below.
            Are you currently employed?
            Do you have paystubs from the most recent four consecutive weeks?
            (You may select & upload multiple files)
            Drop files here or
            Max. file size: 300 MB.
              If you cannot provide paystubs, please select the additional proof of income that you will be providing.
              (If you are uploading more than one document, you can make multiple selections. The Verification of Earnings form can be found here.)
              The Verification of Earnings form can be found here.
              Max. file size: 300 MB.
              Drop files here or
              Max. file size: 300 MB.
                Max. file size: 300 MB.
                Are you recently unemployed (within the last 12 months)?
                The Certification of Zero Income form can be found here.
                Drop files here or
                Max. file size: 300 MB.
                  Are you a full-time college student?
                  Note: A student must be currently enrolled in 9 or more credit hours to be considered "full-time".
                  Drop files here or
                  Max. file size: 300 MB.
                    Do you have a tax return from the previous year?
                    Max. file size: 300 MB.
                    If you do not have your tax return from the previous year, please explain why.

                    While LVIM can still provide you with primary healthcare 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 not include the applicant(s) in this count.
                    (You may select & upload multiple files)
                    Drop files here or
                    Max. file size: 300 MB.

                      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.

                      Contact

                      600 West Peachtree Street
                      Lakeland, FL 33815
                      863-688-LVIM (5846)
                      Email

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