Primary Care Medical Home
(1-877-754-2623)
Location!
"Qliance makes it easy to
become a patient"
Registration
To become a Qliance patient, simply complete the registration form below and submit it to Qliance. 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. Upon receipt of your form, Qliance Member Services 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. It's that simple!
Adult Registration:
Adult Registration Form
Medical Record Transfer Form
Adult Medical History Form
Child Registration:
Child Registration Form
Medical Record Transfer Form
Child Medical History Form
Medicare Forms:
Questions
If you have questions about becoming a member,
please call Qliance Member Services at (206) 381-3030 or email Qliance.
