Prerequisites for Patient Portal - Lakeland Volunteers in Medicine

Do you live in Polk County?*

Yes
No

We're sorry, but you do not qualify for LVIM's services. Please visit this link for some alternative resources.

Or, call us today at 863-688-5846 X104 or 105. We would be happy to schedule an appointment for you with a patient navigator who can help you find another quality healthcare provider that fits your situation.

Do you have health insurance of any kind (including Medicaid & Medicare)?*

Yes
No
I have Medicaid Share of Cost.

Please select NO if you ONLY have dental and/or vision insurance.

LVIM may still be able to help if you have Medicaid Share of Cost.

We're sorry, but you do not qualify for LVIM's services. Please visit this link for some alternative resources.

Or, call us today at 863-688-5846 X104 or 105. We would be happy to schedule an appointment for you with a patient navigator who can help you find another quality healthcare provider that fits your situation.

Do any of the scenarios listed below apply to you?*

Yes
No

- I have a traditional job (receive paystubs)

-I work, but do not receive paystubs

-I work as an independent contractor and receive a 1099 - I work for cash

- I am self-employed, with IRS Schedule SE

- I am a caregiver (Mothers/fathers/guardians caring for children; adult children caring for elderly parents; caring for a disabled spouse; providing care in exchange for room and board)

-I am 18 years or older AND a full-time student (enrolled in 9 or more credit hours) NOT declared by my parents

-I am unemployed and lost my job within the last year

- I am disabled and awaiting approval for disability income

- I receive Social Security income as my only source of income

- I am a resident of Lighthouse Ministries, Salvation Army, or Talbot House

We're sorry, but you do not qualify for LVIM's services. Please visit this link for some alternative resources.

Or, call us today at 863-688-5846 X104 or 105. We would be happy to schedule an appointment for you with a patient navigator who can help you find another quality healthcare provider that fits your situation.

Is your TOTAL household income below 200% of the Federal Poverty Level?*

Click here to check.

Yes
No

We're sorry, but you do not qualify for LVIM's services. Please visit this link for some alternative resources.

Or, call us today at 863-688-5846 X104 or 105. We would be happy to schedule an appointment for you with a patient navigator who can help you find another quality healthcare provider that fits your situation.

Can you provide documentation to support the responses to the questions you just answered?*

Click here for a list of documents we accept.

Yes
No

We're sorry, but you do not qualify for LVIM's services. Please visit this link for some alternative resources.

Or, call us today at 863-688-5846 X104 or 105. We would be happy to schedule an appointment for you with a patient navigator who can help you find another quality healthcare provider that fits your situation.

According to your responses here, you may qualify for LVIM's services!

You may now complete your LVIM Application.

To complete your application online, please click the button below.

If you'd prefer to complete the application in-person or with the assistance of a member of our team, you may contact us at (863) 688-5846, ext 104 or 105.

We're excited to connect you to healthcare for the community, by he community!

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