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

Authorization Request Forms/Certification/Letter of Medical Necessity

OMB: 1240-0055

IC ID: 221978

Information Collection (IC) Details

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CA-27, Authorization Request form and Certification/Letter of Medical Necessity for Opioie Medications
 
No Unchanged
 
Required to Obtain or Retain Benefits
 
20 CFR 10.809 20 CFR 10.310 20 CFR 10.800

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CA-27 Authoriization/Request Form and Certification/Letter of Medical Necessity for Opioid Medications CA 27 LMN Opioids.pdf Yes Yes Fillable Printable

Health Health Care Services

DOL/GOVT-1  67 FR 16826

154,500 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 154,500 0 0 0 0 154,500
Annual IC Time Burden (Hours) 77,250 0 0 0 0 77,250
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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