Information Collection

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

IC 221978 under ICR 202405-1240-002 · OMB 1240-0055.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CA-27 CA-27, Authorization Request form and Certification/Letter of Medical Necessity for Opioid Medications	Form and Instruction
CA 27 LMN Opioids Instructions.pdf	Instruction
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 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
CA-27 (Web) Authorization Request form and Certification/Letter of M CA-27 LMNOpioid-UAT with Burden Statement.PNG	Form and Instruction

IC Title:

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 10.800 20 CFR 10.809 20 CFR 10.310

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 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

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: 490

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	490	-44,610	45,100
Annual IC Time Burden (Hours)	245	-22,305	22,550
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.