- Qliance

Experience Healthcare The Way It Should Be

Become a Qliance member and receive the very best in primary care and telemedicine! Our members have access to unlimited care without the burden of copays, co-insurance, or deductibles. All Qliance members are also enrolled in Qliance telemedicine at no additional fee, meaning that 24/7 access to care is available to you at anytime and anyplace.

Fill out our registration form below to join today!

If you are unable to signup online, please download a registration form HERE and submit using one of the following options:

By Email:
By Fax: 1-206-381-3035
Or dial 1-877-754-2623 for assistance

Qliance Online Registration

Please complete the requested information below to begin the registration process. Once submitted, you will receive a confirmation email with further instructions on how to activate your membership. You will not be billed any membership fees until you have activated your account with one of our Member Service Representatives.

If you are a human and are seeing this field, please leave it blank.

Fields marked with an * are required

Individual Unique ID

First Name *

Middle Initial

Last Name *

Date of Birth *

Email *

SSN

Address 1 *

Address 2

City *

State *

Zip Code *

Daytime Phone *

Evening Phone

Mobile Phone

Subgroup Name

Status

Insurance Company Name

Insurance Plan Name

Insurance Group Number

Insurance Member Number

Eligibility Effective Date

Eligibility Term Date

Dependent of Individual Unique ID

Dependent Relationship Code

Risk Code

Monthly Membership Fee

One Time Registration Fee

Total First Month Fees

Qliance Member Services

Prescription Refills

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