CA-27, Authorization Request form and Certification/Letter of Medical Necessity for Opioid Medications

Authorization Request Form/Certification/Letter of Medical Necessity

Documents and Forms

Document Name Document Type
Form CA-27 CA-27, Authorization Request form and Certification/Letter of Medical Necessity for Opioid Medications Form and Instruction
CA 27 LMN Opioids Instructions.pdf Instruction
CA 27 LMN Opioids Instructions.pdf Instruction
CA-27 Authoriization/Request Form and Certification/Letter of CA 27 LMN Opioids.pdf Form and Instruction
CA-27 Authoriization/Request Form and Certification/Letter of CA 27 LMN Opioids.pdf Form and Instruction
CA-27 (Web) Authorization Request form and Certification/Letter of M CA-27 LMNOpioid-UAT with Burden Statement.PNG Form and Instruction
CA-27 (Web) Authorization Request form and Certification/Letter of M CA-27 LMNOpioid-UAT with Burden Statement.PNG Form and Instruction

Information Collection (IC) Details

IC Title:	CA-27, Authorization Request form and Certification/Letter of Medical Necessity for Opioid Medications	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 10.800 20 CFR 10.809 20 CFR 10.310

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CA-27	Authoriization/Request Form and Certification/Letter of Medical Necessity for Opioid Medications	CA 27 LMN Opioids.pdf	Yes	Yes	Fillable Printable
Instruction			CA 27 LMN Opioids Instructions.pdf	Yes	Yes	Fillable Fileable Signable
Form and Instruction	CA-27 (Web)	Authorization Request form and Certification/Letter of Medical Necessity for Opioid Medications	CA-27 LMNOpioid-UAT with Burden Statement.PNG	Yes	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: DOL/GOVT-1	FR Citation: 81 FR 47418

Number of Respondents: 490	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	490	-44,610	45,100
Annual IC Time Burden (Hours)	245	-22,305	22,550
Annual IC Cost Burden (Dollars)	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.