Information Collection

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

IC 221978 under ICR 201606-1240-003 · OMB 1240-0055.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CA-27 Authoriization/Request Form and Certification/Letter of Medical Necessity for Opioid Medications CA-27, Authorization Request form and Certification/Letter of Medical Necessity for Opioie Medications	Form and Instruction
CA-27 Authoriization/Request Form and Certification/Letter of CA 27 LMN Opioids.pdf	Form and Instruction

IC Title:

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

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CA-27				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: 154,500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	154,500	154,500
Annual IC Time Burden (Hours)	77,250	77,250
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.

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