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

Authorization Request Forms/Certification/Letter of Medical Necessity

OMB: 1240-0055

IC ID: 221978

Information Collection (IC) Details

View Information Collection (IC)

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

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
Instruction CA 27 LMN Opioids Instructions.pdf Yes Yes Fillable Fileable Signable
Form and Instruction CA-27 (Web) Authorization Request form and Certification/Letter of Medical Necessity for Opioid Medications CA-27 LMNOpioid-UAT with Burden Statement.PNG Yes Yes Fillable Fileable Signable

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

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.

© 2024 OMB.report | Privacy Policy