CA-26, Authorization Request Form and Certification/Letter of Medical Necessity for Compounded Drugs

Authorization Request Forms/Certification/Letter of Medical Necessity

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form CA-26 CA-26, Authorization Request Form and Certification/Letter of Medical Necessity for Compounded Drugs Form and Instruction
CA-26 Authorization Request Form and Certification/Letter of M CA 26 LMN Compounded Drugs.pdf Form and Instruction

Information Collection (IC) Details

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: New

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CA-26	Authorization Request Form and Certification/Letter of Medical Necessity for Compounded Drugs	CA 26 LMN Compounded Drugs.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: DOL/GOVT-1	FR Citation: 67 FR 16826

Number of Respondents: 15,500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	15,500	15,500
Annual IC Time Burden (Hours)	7,750	7,750
Annual IC Cost Burden (Dollars)	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.