Information Collection

Authorization Form/Letter of Medical Necessity for Compounded Drugs

IC 267907 under ICR 202405-1240-007 · OMB 1240-0062.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form OWCP-26 Authorization Form/Letter of Medical Necessity for Compounded Drugs	Form and Instruction
OWCP-26 Authorization Request form/Letter of Medical Necessity f Letter of Medical Necessity for Compounded Drugs (OWCP-26).pdf owcprx.dol.gov/portal/main.do	Form and Instruction
OWCP-26 Authorization Request form/Letter of Medical Necessity f Letter of Medical Necessity for Compounded Drugs (OWCP-26).pdf owcprx.dol.gov/portal/main.do	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 10.800 20 CFR 10.310 20 CFR 10.809 20 CFR 725

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	OWCP-26	Authorization Request form/Letter of Medical Necessity for Compounded Drugs	Letter of Medical Necessity for Compounded Drugs (OWCP-26).pdf	https://owcprx.dol.gov/portal/main.do	Yes	Yes	Fillable Fileable Signable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title: DOL/GOVT-1

FR Citation: 20 FR 10

Number of Respondents: 78

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	490	490
Annual IC Time Burden (Hours)	245	245
Annual IC Cost Burden (Dollars)	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.