Qliance makes it easy to
become a patient
Becoming a Patient
To become a member, simply open the registration form below, save it to your computer, and send it back to Qliance Member Services. You may mail, fax or email it to .
Monthly Pricing:
Service Level Options
Qliance offers three levels of services (see Levels 1, 2, 3 below) which are included in your Monthly Care Fee. Regardless of service level, you have unlimited access to a Qliance provider with no copays. Registration fee is $99 per family.
Adult Registration:
Child Registration:
Medicare Forms:
Other Forms:
Adult Medical Record Transfer Form
Adult Health History Form
Child Medical Record Transfer Form
Child Health History Form
Qliance Email Communication Form
Acknowledgement of Privacy Practices, Next of Kin Designation
Questions
If you have questions about becoming a member,
please call us at (206) 381-3030 or .
"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.
