CCS Provider Application

Please use the following documents below to complete your CCS Provider Application with North Central Health Care.

CCS Provider Handbook (.pdf File)

CCS Provider Application (Fillable Word Document)

Budget Request Form (.xlsx file - Excel)

Vendor Direct Deposit Authorization (Fillable Word Document)

Contracted Services Core Competencies/Quality Performance Measures/Code of Conduct Attestation (.pdf file)

Need additional assistance with CCS Budget Request Form? Please read these helpful Budget Packet Instructions (.docx Word Document)

Upon completion, please submit your finished documentation to:
North Central Health Care
C/O Community Treatment Quality Assurance Specialist
1100 Lake View Drive
Wausau, WI 54403
Submit electronically to

If you have any questions, please contact NCHC Community Treatment at 715.843.6120.