Information Collection Request

Authorization Request Form/Certification/Letter of Medical Necessity

ICR 202405-1240-002 · OMB 1240-0055 · Received in OIRA

Forms and Documents

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

Information collection document groups
IC ID	Collection	Type	Status	Form
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

Record metadata
Status	Received in OIRA
Agency/Subagency	DOL/OWCP
OMB Control No	1240-0055
Type of Information Collection	Revision of a currently approved collection
Previous ICR Reference No	202404-1240-005
Date Submitted to OIRA	1969-12-31
Requested Expiration Date	1969-12-31