Dane County Department of Human Services Provider Hub

CCS Provider Forms

Forms for All CCS Staff

Agency Fax Cover Sheet [revised 10/31/2018]
C-SSRS
Release of Information (ROI)
- form-enabled Microsoft Word version
- non-fillable PDF version
Supervision / Clinical Collaboration Log
CCS Service Provider Orientation & Training
- CCS Service Provider Orientation Checklist
- On-going Training Log

Forms for Service Facilitation Staff

Physician Prescription for CCS [added 02/06/2018]
Assessment and Recovery Team Template [revised 02/12/2018]
- C-SSRS
Assessment Summary Template [revised 4/26/2016]
Transfer Summary [added 9/1/2016]
Recovery Team Meeting Roster Template [revised 01/27/2019]
CCS Discharge Summary
- Fillable Discharge Summary
Dane County Mental Health Consumer Status Data Form

Fiscal Forms

Please return the completed direct deposit authorization agreement, W-9, and voided check/direct deposit letter to the Dane County Controller’s Office.

Email: dccontrollersoffice@countyofdane.com

Fax: (608) 266-4425

Mail: 210 Martin Luther King Jr. Blvd, Room 425, Madison, WI 53703