Make Qliance Your Medical Home

To register, please download and complete our patient registration form and return it to Qliance along with a check (payable to "Qliance") for your registration fee and your first month's care fee.

Upon receipt, a Qliance patient care coordinator will open your billing account, set-up your electronic medical record, coordinate the transfer of your medical records (if applicable) and contact you to schedule your first appointment. That’s it!

New Patient Registration Forms

1. Patient Registration Form (Adult)
2. Patient Registration Form (Child)

Other Patient Forms

1. Qliance Brochure
2. Patient Services Guide
3. Medical Record Transfer Form (for patients with medical records at other physician offices)
4. Contract with Medicare Beneficiary (for patients who are Medicare-eligible)

Questions

If you have a question about become a Qliance member, please call the Qliance business office at (206) 381-3030 or email Qliance.