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CA-26, Authorization Request Form and Certification/Letter of Medical Necessity for Compounded Drugs
Authorization Request Forms/Certification/Letter of Medical Necessity
OMB: 1240-0055
IC ID: 221977
OMB.report
DOL/OWCP
OMB 1240-0055
ICR 201906-1240-001
IC 221977
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0055 can be found here:
2024-05-30 - Revision of a currently approved collection
2024-04-23 - No material or nonsubstantive change to a currently approved collection
Documents and Forms
Document Name
Document Type
Form CA-26 (Length of T
CA-26, Authorization Request Form and Certification/Letter of Medical Necessity for Compounded Drugs
Form
CA 26 LMN Compounded Drugs - Instructions pages 3 to 5.pdf
Instruction
CA-26 Authorization Request form and Certification/Letter of M
LMN compounded Drug form-updated xx.png
Form
CA-26 (Method of A Authorization Request Form and Certification/Letter of M
LMN compounded Drug form-Route of Admin DDL-updted.png
Form
CA-26 (Length of T Authorization Request Form and Certification/Letter of M
LMN compounded Drug form-Length of Therapy DDL-updtd.png
Form
CA-26 Authorization Request form and Certification/Letter of M
CA 26 LMN Compounded Drugs.pdf
Form
CA-27 Authorization Request form and Certification/Letter of M
CA 27 LMN Opioids.pdf
Form
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
CA-26, Authorization Request Form and Certification/Letter of Medical Necessity for Compounded Drugs
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
20 CFR 10.809
20 CFR 10.310
20 CFR 10.800
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
CA-26 (Length of Therapy Detail
Authorization Request Form and Certification/Letter of Medical Necessity for Compunded Drugs (Length of Therapy Detail)
LMN compounded Drug form-Length of Therapy DDL-updtd.png
Yes
Yes
Fillable Fileable Signable
Instruction
CA 26 LMN Compounded Drugs - Instructions pages 3 to 5.pdf
Yes
Yes
Fillable Fileable Signable
Form
CA-26 (Method of Administration Detail)
Authorization Request Form and Certification/Letter of Medical Necessity for Compunded Drugs (Methods of Administration Detail
LMN compounded Drug form-Route of Admin DDL-updted.png
Yes
Yes
Fillable Fileable Signable
Form
CA-26
Authorization Request form and Certification/Letter of Medical Necessity for Compounded Drugs
LMN compounded Drug form-updated xx.png
Yes
Yes
Fillable Fileable Signable
Form
CA-26
Authorization Request form and Certification/Letter of Medical Necessity for Compounded Drugs
CA 26 LMN Compounded Drugs.pdf
Yes
Yes
Fillable Fileable Signable
Form
CA-27
Authorization Request form and Certification/Letter of Medical Necessity for Opioid Medications
CA 27 LMN Opioids.pdf
Yes
Yes
Fillable Fileable Signable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Workforce Management
Subfunction:
Labor Rights Management
Privacy Act System of Records
Title:
DOL/GOVT-1
FR Citation:
81 FR 47418
Number of Respondents:
500
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
100 %
Requested
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
500
0
0
-15,000
15,500
0
Annual IC Time Burden (Hours)
250
0
0
-7,500
7,750
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
No associated records found
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.