Make Qliance Your Medical Home

To register, please print and complete our patient registration form and return it to Qliance along with payment for your registration fee. Upon receipt, a Qliance member services associate 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!

Patient Registration Forms

• Patient Registration Form 
• Medical History Form (Adult) / (Child)
• Medical Record Transfer Form (if you have medical records you would like transferred)
• Medicare Beneficiary Form (for Medicare eligible patients)

Other Documents

• Qliance Patient Services Guide
• Qliance Brochure 
• Qliance Termination Form

Questions

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