Information Collection

CA-26, Authorization Request Form and Certification/Letter of Medical Necessity for Compounded Drugs

IC 221977 under ICR 201612-1240-008 · 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⚠️ Notice: This information collection may be referencing outdated material.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-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

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: Unchanged

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:

table that charts list of 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 %

table that charts list of burden
	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

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.