NATIONAL TESTING SERVICES (CPS AUTHORIZATION FORM)

NATIONAL TESTING SERVICES

PROVIDING ALL OF YOUR SCREENING NEEDS
Authorization Form

For MS Dept of Child Protective Services

1520 Adeline St., Ste 20 Hattiesburg, MS 39401

Ph: (601) 602-2445 Fax: (601) 336-7185

nationaltestingservices@gmail.com

*Submission of this form and the Purchase Order number is required prior to the provision of any services.*
County*
PO#*
Social Worker*
Supervisor*
Social Worker's Email: (ends with @mdcps.ms.gov*
Phone*
I am requesting all services checked below and confirm that the Mississippi Department of Child Protective Services is responsible for payment within 45 days of service.
Social Workers Signature*

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Date*

MonthDayYear
Date
Client/ Donor's Legal Name*
ID
Observation required*
Notes
RAPID TESTS

RAPID U/A 20 Panel $50Fentanyl Conf. $28Tianeptine (Za-Za) Conf. $43K2 (Spice) Conf. $38Other Test Confirmation: $25/ test. Enter drug name below.
ORAL RAPID $50
Conf. for: $26/each drug

FentanylBuprenorphineOther Test Confirmation: $20/ test. Enter drug name below.
ORAL LAB TEST (Lab Send-out)

5 Panel $6010 Panel $70
Conf. for $26/each

FentanylBuprenorphineOther Test Confirmation: $20/ test. Enter drug name below.
DNA

LEGAL/ COURT ORDERED $325ANY ADDITIONAL DONORS $75
HAIR

5 Panel $1607 Panel $17010 Panel $21513 Panel $22517 Panel $325ETG $175Child Guard $188
URINE LAB TEST

5 Panel $5510 Panel $6514 Panel $80ETG $45Fentanyl $70Tianeptine (Za-Za) $75K2 (Spice) $60Fentanyl Conf. $28Tianeptine (Za-Za) Conf. $43K2 (Spice) Conf. $38Other Test Confirmation: $25/ test. Enter drug name below.
NAIL

5 Panel $2207 Panel $27510 Panel $29016 Panel $420ETG $189
ADDITIONAL FEES

HOME VISIT $100, +MileageCPS OFFICE VISIT $.70/ MILEAfter- hours / Weekend ( 5 am- 8 am) $100
*Mileage begins at the NTS Office*
National Testing Services LLC (NTS) cannot confirm any positive results. If confirmation is not requested on this authorization form, the specimen may be discarded and will not be sent to the laboratory for confirmation. Please note, there is an additional charge for confirmation; however, NTS will waive the confirmation fee for one drug per test.
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