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Light of the World Clinic is a free health care clinic. 

Do you need to see a doctor or get a general check-up, but are uninsured and unable to pay for medical care?

You might qualify for the comprehensive services offered by the Light of the World Clinic and its talented volunteer staff. Click here to see our services

The clinic with its 300+ volunteers and 50+ licensed providers donate over 7,500 service hours to help and treat the clinic’s qualified patients.

The clinic is NOT a walk-in clinic and requires prior qualification before any appointments can be given. Sorry, but no exceptions!

To begin the qualification process, please stop by the clinic and pick up an application packet, or you can follow the instructions listed below and submit your application by mail or the online form below:

MAIL IN APPLICATIONS:

1) Download the application packet by clicking the button below.

2) Completely fill in and sign pages 3, 4 & 5 of the application packet – do not leave any spaces blank as this may delay the approval process.  If something does not apply to you, simply mark N/A or indicate that this does not apply to you.

3) Attach a copy of the necessary documents as indicated on page 2 of the application packet.

4)  Once you have completed the form, mail OR drop off your completed applications along with the proper documentation to the address below.  Please note that all applications require your original signature and therefore, NO Faxed or Emailed Applications can be accepted.

NOTE:  Please keep in mind that incomplete applications and incomplete documentation submittals will delay the approval and processing of your application.

DOWNLOAD THE PATIENT APPLICATION FORM

Once we have received your completed application either by mail, online or in person, it takes approximately 3-7 days for a response.

We look forward to assisting you in the near future!

Patient Eligibility Coordinator:

Light of the World Clinic, Inc. 5333 N. Dixie Hwy #201, Oakland Park, FL 33334

Office: (954) 563-9876 ext. 206

Before filling in the application below please download and read the application document requirements. You application will not be complete if we do not receive the necessary documents.

ONLINE APPLICATIONS:

1) Completely fill in and sign the form below – do not leave any spaces blank as this may delay the approval process.  If something does not apply to you, simply mark N/A or indicate that this does not apply to you.

2) All applications require your original signature and therefore, NO Faxed or scanned applications can be accepted.

NOTE:  Please keep in mind that incomplete applications and incomplete documentation submittals will delay the approval and processing of your application.

APPLICATION DOCUMENT REQUIREMENTS

ONLINE PATIENT APPLICATION:

Date:
Do you have health or dental insurance for you or anyone in your family?
Address:
Date Of Birth
Male/ Female
Race: (Must Choose an Answer):
Ethnicity:
Do you file a yearly tax return?
Marital Status
Are you a Veteran?
Please check the following:
Is this application for:
(If this is a family application, please list each uninsured family member that you wish to include on this application and include their Name, DOB and Occupation in the space below.)
APPLICANT / SELF
NAME
DOB
OCCUPATION
SPOUSE
NAME
DOB
OCCUPATION
CHILD #1
NAME
DOB
OCCUPATION
CHILD #2
NAME
DOB
OCCUPATION
CHILD #3
NAME
DOB
OCCUPATION
Please take a moment to review and initial the following statements to show you understand these policies.
DATE:

Emergency Room & Hospital History: (To be completed by Head of Household requesting clinic services)

NOTE: If you have been to the ER or hospital in the last year, and you can find your discharge papers from that visit, please bring them to your first appointment. That will help your nurse and doctor understand what happened at the ER and give you better care.

ER History within the past year:

In the last year, have you been to a hospital’s Emergency Room (ER)? If yes, please fill out the information below:
Approx date of visit (only within the last year)
Approx date of visit (only within the last year)
Approx date of visit (only within the last year)
Approx date of visit (only within the last year)

Hospital History within the past year:

In the last year, have you been admitted to a hospital? If yes, please fill out the information below:
Approx date of visit (only within the last year)
Approx date of visit (only within the last year)
Approx date of visit (only within the last year)
Approx date of visit (only within the last year)

Consent and Signature

I, hereby, consent to the release of my demographic information only (name, address, social security number, and date of birth) to Broward Health, Holy Cross Hospital and they may release information to LOTWC on services provided, for the purpose of tracking whether cost savings have been achieved through primary care services offered at LOTWC.
Date
Signature: I certify by my signature that, to the best of my knowledge, the information entered in this Eligibility Form and Health Summary Form is true and complete. I further understand that failure to provide accurate information may result in discharge from Light of the World Clinic (LOTWC).
Date Signed

PLEASE SIGN BELOW

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

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