Authorization Form/Letter of Medical Necessity for Compounded Drugs

Authorization Request Form and Certification /Letter of Medical Necessity for Compounded Drugs (OWCP-26)

Documents and Forms

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

Information Collection (IC) Details

IC Title:	Authorization Form/Letter of Medical Necessity for Compounded Drugs	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:

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 %

	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

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.