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Step 1 of 4

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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 104 or 105.

Si necesita ayuda para completar esta solicitud debido a una barrera del idioma, llame al (863) 688-5846, extensión 104 o 105.

Please fill in the fields below with the information of the adult client who is applying to receive care.

Client Information

Client Name(Required)
Is this client a new or an existing LVIM client?(Required)
Are you a new or an existing LVIM client?(Required)
Address(Required)

Family Size

Please fill in the fields below regarding the size and makeup of your household. For the purposes of this application, a household is the Applicant + Partner/Spouse + Legal Dependents. (If you are the only person in the household according to this definition, please answer "1.")
Are any adults (18-21) in the household full-time students?(Required)
Are there children (under 18 years of age) in the household?(Required)
Do you wish to enroll any of your uninsured children in LVIM's services?(Required)
Is anyone in the household pregnant?(Required)

Identification

If you do not have an ID, you may still qualify.  Please complete the application and an enrollment coordinator will contact you. 
Do you have any form of identification?(Required)
(Driver’s License, Passport (foreign or domestic), State ID, ID card from foreign consulate, etc.)
Max. file size: 300 MB.
If you do not have an ID, you may still qualify.  Please complete the application and an enrollment coordinator will contact you. 

Proof of Polk County, FL Residency

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.
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

*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.

ALL documents MUST be in the client's name and show the client's current Polk County address.

For secondary documents, client may submit any document from the above list OR one of the following:
  1. Voter's Registration

  2. Proof of children registered in Polk County schools

  3. Verification from Polk County probation officer

  4. Verification of homeless status

  5. Letter from a residential program or institute (e.g. Talbot House, Lighthouse Ministries, Salvation Army, Gospel Village, etc.)

A photo ID is not required, but can serve as proof of residency in Polk County and streamline some processes. If available, please submit a current ID for for each adult (18+) in the household seeking care. Multiple files can be uploaded in the form fields below.
LVIM requests that each client have TWO proofs of Polk County residency on file. Please select the FIRST documents you will be submitting from the list below.(Required)
Drop files here or
Max. file size: 300 MB.
    Please select the SECOND proof of residency that you will be providing.(Required)
    (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.

        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?(Required)
        Do you have paystubs from the most recent four consecutive weeks?(Required)
        (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.(Required)
          (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)?(Required)
            The Certification of Zero Income form can be found here.
            Drop files here or
            Max. file size: 300 MB.
              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?(Required)
                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?(Required)
                  Max. file size: 300 MB.
                  If you do not have your tax return from the previous year, please explain why.(Required)

                  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 you receive any unearned income? (i.e. Alimony, Social Security Retirement or Disability, Child Support, dividends & interest, payments from unemployment or Worker's Compensation Benefits)(Required)
                  Max. file size: 300 MB.
                  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.

                        

                       

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                    600 West Peachtree Street
                    Lakeland, FL 33815
                    863-688-5846

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