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

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⚠️ Notice: This information collection may be referencing outdated material.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
CA 27 LMN Opioids Instructions.pdf Instruction
CA-27 Authoriization/Request Form and Certification/Letter of CA 27 LMN Opioids.pdf Form and Instruction
CA-27 (Web) Authorization Request form and Certification/Letter of M CA-27 LMNOpioid-UAT with Burden Statement.PNG Form and Instruction

Information Collection (IC) Details

IC Title:	CA-27, Authorization Request form and Certification/Letter of Medical Necessity for Opioid Medications	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 10.310 20 CFR 10.800 20 CFR 10.809

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
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
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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: DOL/GOVT-1	FR Citation: 81 FR 47418

Number of Respondents: 45,100	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	45,100	-109,400	154,500
Annual IC Time Burden (Hours)	22,550	-54,700	77,250
Annual IC Cost Burden (Dollars)	0	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.