Qliance makes it easy to
become a patient

Becoming a Patient

To become a member, simply complete the registration form below and send it back to Qliance Member Services who will establish your patient and billing account, set up your electronic medical record, coordinate the transfer of your medical records (if requested) and confirm your new membership. You may mail, fax or email it to registration@Qliance.com. To simplify your registration, you may start your membership at any time; your service start date will be the same as your billing date. It's that simple!

Adult Registration:

Adult Registration Packet

Child Registration:

Child Registration Packet

Medicare Forms:

Medicare Beneficiary Form

Other Forms:

Adult Medical Record Transfer Form
Adult Health History Form

Child Medical Record Transfer Form
Child Health History Form

Questions

If you have questions about becoming a member, please call us at (206) 381-3030 or email Qliance.

"Qliance is absolutely awesome. I feel like I've gone back in time to 1950. Both times I've walked into the doctor's office, they've treated me like I'm human!"

-Patient Chad B.