CA-27 (Web) Authorization Request form and Certification/Letter of M

Authorization Request Forms/Certification/Letter of Medical Necessity

CA-27 LMNOpioid-UAT with Burden Statement.PNG

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

OMB: 1240-0055

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 1240-0055 can be found here:

2024-04-23 - No material or nonsubstantive change to a currently approved collection
2020-02-12 - Reinstatement without change of a previously approved collection

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