Prerequisites for Patient Portal - Lakeland Volunteers in Medicine

Email

This field is for validation purposes and should be left unchanged.

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, please call 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)? 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.*

Yes
No
I 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 am self-employed.

- 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 12 or more credit hours) NOT declared by my parents

-I became unemployed within the last 12 monhts

- I receive Social Security Retirement income as my only source of income, but am not enrolled in Medicare

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

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 'Apply Online' below.

If you'd prefer to speak with a member of the LVIM team and have them assist in completing an application, please call (863) 688-5846, ext 104 or 105. Members of our enrollment team are available Monday through Thursday, 8 a.m. to 4 p.m., and Fridays 8 a.m. until noon.

¿No hablas Inglés?

Estamos trabajando arduamente para que nuestro sitio web esté actualizado y disponible en español. Sin embargo, hasta que podamos, tenga en cuenta que contamos con miembros del equipo bilingües disponibles varios días a la semana y que estaremos encantados de atenderle. Para hablar con un miembro del equipo de LVIM y pedirle que le ayude a verificar su elegibilidad y completar una solicitud, llame al (863) 688-5846, extensión 104 o 105. Los miembros de nuestro equipo de inscripción están disponibles de lunes a jueves, de 8 a. m. a 4 p. m., y los viernes, de 8 a. m. a mediodía.

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

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