Authorization Request Forms/Certification/Letter of Medical Necessity

ICR 202404-1240-005

OMB: 1240-0055

Federal Form Document

⚠️ Notice: This information collection may be outdated. More recent filings for OMB 1240-0055 can be found here:

2024-05-30 - Revision of a currently approved collection

Forms and Documents

Document Name	Status
Form CA-27 CA-27, Authorization Request form and Certification/Letter of Medical Necessity for Opioid Medications Form and Instruction	Unchanged
Form CA-27 CA-27, Authorization Request form and Certification/Letter of Medical Necessity for Opioid Medications Form and Instruction	Unchanged
Form CA-26 CA-26, Authorization Request Form and Certification/Letter of Medical Necessity for Compounded Drugs Form	Modified
Form CA-26 CA-26, Authorization Request Form and Certification/Letter of Medical Necessity for Compounded Drugs Form	Modified
Justification CA-26_MN_4.26.24 amended clean.docx Justification for No Material/Nonsubstantive Change	2024-04-26
Supporting Statement 1240-0055_1.14.2020.docx Supporting Statement A	2024-04-26
Supporting Statement 1240-0055 - EC_MN2 nonsub 4.22.2024 - EC clean.docx Supporting Statement A	2024-04-23
Justification CA-26_MN 4.22.2024_OWCP Approved.docx Justification for No Material/Nonsubstantive Change	2024-04-23
Justification CA-26_MN 4.22.2024_OWCP Approved.docx Justification for No Material/Nonsubstantive Change	2024-04-23
CA 26 LMN Compounded Drugs - highlighted change areas.pdf Supplementary Document	2024-04-22
CA 26 LMN Compounded Drugs - highlighted change areas.pdf Supplementary Document	2024-04-22
Privacy Act Systems-FECA.docx Supplementary Document	2019-06-10
Privacy Act Systems-FECA.docx Supplementary Document	2019-06-10
OPM Salary Table 2019.pdf Supplementary Document	2019-06-10
OPM Salary Table 2019.pdf Supplementary Document	2019-06-10
Physicians and Surgeons, All Other occupational employment and wages 2018.htm Supplementary Document	2019-06-10
Physicians and Surgeons, All Other occupational employment and wages 2018.htm Supplementary Document	2019-06-10

IC Document Collections

IC ID	Document Title	Status
221978	CA-27, Authorization Request form and Certification/Letter of Medical Necessity for Opioid Medications Form and Instruction	Unchanged
221978	CA-27, Authorization Request form and Certification/Letter of Medical Necessity for Opioid Medications Form and Instruction	Unchanged
221977	CA-26, Authorization Request Form and Certification/Letter of Medical Necessity for Compounded Drugs Form	Modified
221977	CA-26, Authorization Request Form and Certification/Letter of Medical Necessity for Compounded Drugs Form	Modified

ICR Details

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