Forms

Please open the following forms with Adobe Reader or another PDF reader, by downloading to your desktop and filling out there. Once done, the Submit button will prompt you to automatically send the form in to our Help Desk. 

Reliance Enrollment Form – Long Form.

        For large, multi-provider or multi-location organizations

Reliance Enrollment Form – Short Form.

        For enrolling organizations with 3 or fewer locations and/or 6 or fewer providers

Reliance Provider Change Form.

        For those organizations currently with Reliance needing to update, add, or remove listed providers

Reliance Add/Remove User Form.

        For those organizations currently with Reliance needing to add or remove users

 

If you are experiencing any issues with our forms please contact HelpDesk@RelianceHIE.org or call (855) 290-5443 Option 1