Authorization Request Form/Certification/Letter of Medical Necessity

ICR 202405-1240-002

OMB: 1240-0055

Federal Form Document

Forms and Documents

Document Name	Status
Form CA-27 CA-27, Authorization Request form and Certification/Letter of Medical Necessity for Opioid Medications Form and Instruction	Modified
Form CA-26 CA-26, Authorization Request Form and Certification/Letter of Medical Necessity for Compounded Drugs Form	Removed
60 day FRN.corrected for 1240-055 03.26.2024.pdf Supplementary Document	2024-05-06
60 day FRN for 1240-0055. published 01.26.2024.pdf Supplementary Document	2024-05-06
Privacy Act Systems-FECA.docx Supplementary Document	2024-05-06
OPM 2024 Salary Table.pdf Supplementary Document	2024-05-06
Physians And Surgeons, All Other Occupational Employment And Wages 2022.pdf Supplementary Document	2024-05-06
Supporting Statement 1240-0055.updated 20240506_MN.clean copy.docx Supporting Statement A	2024-05-07

IC Document Collections

IC ID	Document Title	Status
221978	CA-27, Authorization Request form and Certification/Letter of Medical Necessity for Opioid Medications Form and Instruction	Modified
221977	CA-26, Authorization Request Form and Certification/Letter of Medical Necessity for Compounded Drugs Form	Removed