OMB.report

Federal forms, ICRs, and supporting documents

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 NameDocument Type
Form CA-27
CA-27, Authorization Request form and Certification/Letter of Medical Necessity for Opioid Medications		 Form and Instruction
Form CA-27
Authoriization/Request Form and Certification/Letter of Medical Necessity for Opioid Medications CA-27, Authorization Request form and Certification/Letter of Medical Necessity for Opioid Medications		 Form and Instruction
Form CA-27 (Web)
Authorization Request form and Certification/Letter of Medical Necessity for Opioid Medications 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

Information Collection (IC) Details

View Information Collection (IC)

layout table

Information Collection Instruments:
table that charts list of instruments
Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CA-27 Yes Yes Fillable Printable
Instruction Yes Yes Fillable Fileable Signable
Form and Instruction CA-27 (Web) Yes Yes Fillable Fileable Signable

Federal Enterprise Architecture Business Reference Module


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

Documents for IC
table that charts IC Documents
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            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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