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Dane County Department of Human Services Provider Hub

Provider Application Process

Dane County Department of Human Services (DCDHS) manages the CCS Provider Network. The Provider Network Coordinator at Dane County handles the processing of applications for new provider agencies to join the network as well as the initial and ongoing verification of CCS staff credentials.

A detailed description of the application process may be found in the CCS Provider Handbook.

Application Materials

Applications are available online here:

For a paper copy of an application, contact the Provider Network Coordinator at:

CCS Provider Network Coordinator
Department of Human Services
1202 Northport Dr.
Madison, WI 53704

Phone: (608) 242-6453
Fax: (608) 283-2994
Email: ccs@countyofdane.com

IRS W-9 Form

This IRS W-9 Form must be submitted at the time of application.


Request for Taxpayer ID Number & Certification Form
Usual & Customary Rate Schedule

Service Providers are required to submit a Usual & Customary Rate Schedule at the time of application if requesting rates below Dane County interim rates for any of the billing levels.


Microsoft Excel Fillable Form
Staff Listing

Service Providers are required to notify the Provider Network Coordinator of any changes in staff and provide an updated CCS staff listing form with the supporting documentation at the time of application and within 30 days of personnel changes.


CCS Staff Listing
Contract

This is a draft of the CCS contract boilerplate with Dane County.


CCS Contract Boilerplate