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⚠️ Notice: This information collection may be referencing outdated material.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
CA 26 LMN Compounded Drugs - Instructions pages 3 to 5.pdf Instruction
CA-26 Authorization Request form and Certification/Letter of M LMN compounded Drug form-updtd.png Form
CA-26 (Method of A Authorization Request Form and Certification/Letter of M LMN compounded Drug form-Route of Admin DDL-updted.png Form
CA-26 (Length of T Authorization Request Form and Certification/Letter of M LMN compounded Drug form-Length of Therapy DDL-updtd.png Form

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: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 10.809 20 CFR 10.310 20 CFR 10.800

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CA-26	Authorization Request form and Certification/Letter of Medical Necessity for Compounded Drugs	LMN compounded Drug form-updtd.png	Yes	Yes	Fillable Fileable Signable
Form	CA-26 (Method of Administration Detail)	Authorization Request Form and Certification/Letter of Medical Necessity for Compunded Drugs (Methods of Administration Detail	LMN compounded Drug form-Route of Admin DDL-updted.png	Yes	Yes	Fillable Fileable Signable
Form	CA-26 (Length of Therapy Detail	Authorization Request Form and Certification/Letter of Medical Necessity for Compunded Drugs (Length of Therapy Detail)	LMN compounded Drug form-Length of Therapy DDL-updtd.png	Yes	Yes	Fillable Fileable Signable
Instruction			CA 26 LMN Compounded Drugs - Instructions pages 3 to 5.pdf	Yes	Yes	Fillable Fileable Signable

Line of Business: Workforce Management

Subfunction: Labor Rights Management

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	Previously Approved
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.