Jon Testing Post - Lakeland Volunteers in Medicine

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Name(Required)

First Last

Email(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)

I am the client

I am completing this application on behalf of someone else.

What is your preferred language?(Required)

English

Spanish

Other

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)

First Last

Date of Birth (MM/DD/YYYY)(Required)

Is this client a new or an existing LVIM client?(Required)

New Client

Existing Client

Are you a new or an existing LVIM client?(Required)

New Client

Existing Client

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(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.")

How many adults (18+) are in the household?(Required)

Please describe your relationship to the other adults (18+) in the household.(Required)

Please list the names and dates of birth of the adults in the household who are seeking to receive care from LVIM.(Required)

Are any adults (18-21) in the household full-time students?(Required)

Yes

Are there children (under 18 years of age) in the household?(Required)

Yes

How many children (under 18) live in the household?(Required)

Do you wish to enroll any of your uninsured children in LVIM's services?(Required)

Yes

Please list names and dates of birth of children in the household who are seeking to receive care from LVIM.(Required)

Is anyone in the household pregnant?(Required)

Yes

How many unborn children are there in the household?(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)

Yes

(Driver’s License, Passport (foreign or domestic), State ID, ID card from foreign consulate, etc.)

Please upload a photo or scanned copy of your ID.(Required)

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:

Current Florida Driver's License or State ID with correct address
Electric bill in client’s name
Current Vehicle Registration in client's name
Proof of ownership or purchase of homestead property in Polk County
Rent receipt for most recent week/month
Lease agreement showing current address and client's name
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:

Voter's Registration
Proof of children registered in Polk County schools
Verification from Polk County probation officer
Verification of homeless status
Letter from a residential program or institute (e.g. Talbot House, Lighthouse Ministries, Salvation Army, Gospel Village, etc.)

How many adults (18+) in the household are seeking care?(Required)

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)

Florida driver's license or state ID (showing client's current Polk County address)

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

I don't have any of the items listed above

Please upload your first proof of residency here.(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)

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

Voter's Registration

Paystubs with current address

Proof of children registered in Polk County schools

Verification from Polk County probation officer

Verification of homeless status

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

I don't have any of the items listed above

Upload either the Rental Verification Form or the Declaration of Domicile form(Required)

You can download the Rental Verification form here and the Declaration of Domicile form here.

Drop files here or

Max. file size: 300 MB.

Please upload your second proof of residency here.(Required)

(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)

Yes

Name of Current Employer(Required)

Do you have paystubs from the most recent four consecutive weeks?(Required)

Yes

Please upload your four most recent weeks of consecutive paystubs:(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.)

Verification of Earnings form signed by your employer(s)

Schedule SE (if self-employed) If your business is new, expense records are required (bank statements or profit & loss statements)

Social Security Benefits award letter

Unemployment Award letter

I do not have income.

Please upload the Verification of Earnings form signed by your employer(s)(Required)

The Verification of Earnings form can be found here.

Max. file size: 300 MB.

Please upload the Schedule SE (if self-employed) If your business is new, expense records are required (bank statements or profit & loss statements)(Required)

Drop files here or

Max. file size: 300 MB.

Please upload your Social Security Benefits award letter(Required)

Max. file size: 300 MB.

Are you recently unemployed (within the last 12 months)?(Required)

Yes

Please upload your Termination Letter or last paystub received AND Certification of Zero Income form(Required)

The Certification of Zero Income form can be found here.

Drop files here or

Max. file size: 300 MB.

Please upload Certification of Zero Income form(Required)

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".

Yes

Please upload your current course schedule documenting enrollment in at least 9 credit hours AND your student ID(Required)

Drop files here or

Max. file size: 300 MB.

Do you have a tax return from the previous year?(Required)

Yes

Please upload your 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)

Didn't file

Filed for an extension

Lost it

Other

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)

Yes

Please upload your Unearned Income documentation.(Required)

Max. file size: 300 MB.

How many other members of your household earn an income?(Required)

Do not include the applicant(s) in this count.

Please provide the first and last name(s) of the other members of your household who earn an income(Required)

Please upload the additional proof(s) of income for the other members of your household here. (Please note: if other adults in your household are not earning an income, you will need to submit the Certification of Zero Income form.)(Required)

(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.

Client Information

Family Size

Identification

Proof of Polk County, FL Residency

Clients must upload one of the following items:

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

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.

Proof of Income

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

Multiple files can be uploaded in the form fields below.

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