Forms 2017-10-27T21:14:23+00:00


To join Reliance, please complete and submit the following Reliance Enrollment Form:

Reliance Enrollment Form

Once your clinic or practice is enrolled, you can complete and submit the Reliance Provider Change Form to add or remove health care providers from your practice.

Reliance Provider Change Form

Please Email all completed forms to You can also call 1-855-290-5443 or fax 541-833-0504 for more information.

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