Make Qliance Your Medical Home

To become a Qliance patient, you pay a one-time, $99 registration fee. After you are registered, you pay an affordable monthly care fee based upon your age. For families, the registration fee is charged only once per billing account (not per person). The discounted $39 child rate applies to children (ages 0-19) of adult Qliance patients.

Simply complete our registration form below and submit it to Qliance by mail, fax or email at . Upon receipt, a Qliance Member Services Associate will establish your patient and billing account, set-up your electronic medical records, coordinate the transfer of your medical records (if requested) and confirm your new membership. It's that simple!

New Patient Registration Packets:

• Adult Registration Form
• Child Registration Form
• Medical Records Transfer Form (for patients of Dr. Faith Reeves)

Other Documents for Existing Patients:

• Adult Medical History Form
• Child Medical History Form
• Medical Record Transfer Form
  
• Medicare Beneficiary Form (for Medicare eligible patients)
• Billing Update Form
• Qliance Brochure
• Patient Services Guide
• Service Cancellation Form

Questions

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