Residential/Healthcare Listing

List an account now by filling in the form below. 

If you would like access to our client portal please email: ccbclientservices@ccbinet.com. We will then set you up with secure access to Client View. You can manually turn over accounts, verify balances, and report payments!

 

You can also download a listing sheet to print out and mail in to our Bismarck office.

 

 

Single Listing Sheet (.pdf)

Multiple Listings Sheet (.pdf)

Requires Acrobat Reader

Information Pertaining to Your Business

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Consumer Information    
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Spouse's Information    
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Account Information    
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Insurance Information (if Healthcare account please fill out)    
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Next of Kin Information    
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Patient Information    
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This account is assigned to you with full power and authority to perform all acts necessary for the collection and settlement of said account.