NOTICE TO REVIEWER
Date: October 27, 2016
Request Type: Non-material change
Employing Agency: Office of Workers’ Compensation Programs/Division of Federal Employees’ Compensation
OMB/Expiration Date: 1240-0055, October 31, 2019
The paper version of form CA-26, Authorization Request Form and Certification/Letter of Medical Necessity for Compounded Drugs was recently approved by OMB. As noted in the Supporting Statement with the original submission (item 3), DFEC is now requesting approval for an electronic version of this form. See attached screen shots.
The form will be found on our contracted medical vendor’s website.
The treating physician will have the ability to electronically submit the form to our contracted medical vendor. The electronic version is in the same format as the paper form.
We are also adding the Congressional letter that was inadvertently left out of the documentation when the ICR was first approved.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | NOTICE TO REVIEWER |
| Author | US Department of Labor |
| File Modified | 0000-00-00 |
| File Created | 2021-01-23 |