Information Collection

CA-26, Authorization Request Form and Certification/Letter of Medical Necessity for Compounded Drugs

IC 221977 under ICR 202405-1240-002 · OMB 1240-0055.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CA-26 CA-26, Authorization Request Form and Certification/Letter of Medical Necessity for Compounded Drugs	Form
CA-26 Authorization Request form/Letter of Medical Necessity f LMN compounded Drug form-updated xx.png	Form
CA-26 Authorization Request form/Letter of Medical Necessity f LMN compounded Drug form-updated xx.png	Form
CA-26 (Method of A Authorization Request Form and Certification/Letter of M LMN compounded Drug form-Route of Admin DDL-updted.png	Form
CA-26 (Method of A Authorization Request Form and Certification/Letter of M LMN compounded Drug form-Route of Admin DDL-updted.png	Form
CA-26 (Length of T Authorization Request Form and Certification/Letter of M LMN compounded Drug form-Length of Therapy DDL-updtd.png	Form
CA-26 (Length of T Authorization Request Form and Certification/Letter of M LMN compounded Drug form-Length of Therapy DDL-updtd.png	Form
CA-26 CA-26_Letter of Medical Necessity for Compounded Drugs_n Form OWCP-26 - Letter of Medical Necessity for Compounded Drugs_20240423_Final.pdf	Form and Instruction
CA-26 CA-26_Letter of Medical Necessity for Compounded Drugs_n Form OWCP-26 - Letter of Medical Necessity for Compounded Drugs_20240423_Final.pdf	Form and Instruction
Justification CA-26 (003).docx Justification	IC Document
Justification CA-26 (003).docx Justification	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CA-26	Authorization Request form/Letter of Medical Necessity for Compounded Drugs	LMN compounded Drug form-updated xx.png	Yes	Yes	Fillable Fileable Signable
Form	CA-26 (Method of Administration Detail)	Authorization Request Form and Certification/Letter of Medical Necessity for Compunded Drugs (Methods of Administration Detail	LMN compounded Drug form-Route of Admin DDL-updted.png	Yes	Yes	Fillable Fileable Signable
Form	CA-26 (Length of Therapy Detail	Authorization Request Form and Certification/Letter of Medical Necessity for Compunded Drugs (Length of Therapy Detail)	LMN compounded Drug form-Length of Therapy DDL-updtd.png	Yes	Yes	Fillable Fileable Signable
Form and Instruction	CA-26	CA-26_Letter of Medical Necessity for Compounded Drugs_new 20240422	Form OWCP-26 - Letter of Medical Necessity for Compounded Drugs_20240423_Final.pdf	Yes	Yes	Fillable Fileable Signable

Line of Business: Workforce Management

Subfunction: Labor Rights Management

Privacy Act System of Records

Title: DOL/GOVT-1

FR Citation: 81 FR 47418

Number of Respondents: 500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-500	500
Annual IC Time Burden (Hours)	-250	250
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Justification	Justification CA-26 (003).docx	04/19/2024

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.