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

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CA-26, Authorization Request Form and Certification/Letter of Medical Necessity for Compounded Drugs
 
No Modified
 
Required to Obtain or Retain Benefits
 
20 CFR 10.809 20 CFR 10.310 20 CFR 10.800

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

Workforce Management Labor Rights Management

DOL/GOVT-1  81 FR 47418

500 0
   
Individuals or Households
 
   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

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