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

Information Collection (IC) Details

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

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

Health Health Care Services

DOL/GOVT-1  67 FR 16826

15,500 0
   
Individuals or Households
 
   100 %

  Approved 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 15,500 0 15,500 0 0 0
Annual IC Time Burden (Hours) 7,750 0 7,750 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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