OMB.report

Federal forms, ICRs, and supporting documents

OMB control number

Authorization Request Form/Certification/Letter of Medical Necessity

OMB 1240-0055 · DOL/OWCP.

OMB 1240-0055

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
DocumentType
Form CA-27 (Web) Authorization Request form and Certification/Letter of Medical Necessity for Opioid MedicationsForm and Instruction
Form CA-27 Authoriization/Request Form and Certification/Letter of Medical Necessity for Opioid MedicationsForm and Instruction
Form CA-27 CA-27, Authorization Request form and Certification/Letter of Medical Necessity for Opioid MedicationsForm and Instruction
Form CA-26 CA-26_Letter of Medical Necessity for Compounded Drugs_new 20240422Form and Instruction
Form CA-26 (Length of T Authorization Request Form and Certification/Letter of Medical Necessity for Compunded Drugs (Length of Therapy Detail)Form
Form CA-26 (Method of A Authorization Request Form and Certification/Letter of Medical Necessity for Compunded Drugs (Methods of Administration DetailForm
Form CA-26 Authorization Request form/Letter of Medical Necessity for Compounded DrugsForm
Form CA-26 CA-26, Authorization Request Form and Certification/Letter of Medical Necessity for Compounded DrugsForm
60 day FRN.corrected for 1240-055 03.26.2024.pdf Supplementary Document
60 day FRN for 1240-0055. published 01.26.2024.pdf Supplementary Document
Privacy Act Systems-FECA.docx Supplementary Document
OPM 2024 Salary Table.pdf Supplementary Document
Physians And Surgeons, All Other Occupational Employment And Wages 2022.pdf Supplementary Document
Supporting Statement 1240-0055.updated 20240506_MN.clean copy.docxSupporting Statement A
CA-27, Authorization Request form and Certification/Letter of Medical Necessity for Opioid Medications Form and Instruction
CA-27, Authorization Request form and Certification/Letter of Medical Necessity for Opioid Medications Form and Instruction
CA-27, Authorization Request form and Certification/Letter of Medical Necessity for Opioid Medications Form and Instruction
CA-27, Authorization Request form and Certification/Letter of Medical Necessity for Opioid Medications Instruction
CA-26, Authorization Request Form and Certification/Letter of Medical Necessity for Compounded Drugs Form and Instruction
CA-26, Authorization Request Form and Certification/Letter of Medical Necessity for Compounded Drugs Form
CA-26, Authorization Request Form and Certification/Letter of Medical Necessity for Compounded Drugs Form
CA-26, Authorization Request Form and Certification/Letter of Medical Necessity for Compounded Drugs Form
CA-26, Authorization Request Form and Certification/Letter of Medical Necessity for Compounded Drugs Form

All Historical Document Collections

Historical document collections
ReferenceFilingReceivedConcludedAction
202405-1240-002 Revision of a currently approved collection 2024-05-30 Approved with change
202404-1240-005 No material or nonsubstantive change to a currently approved collection 2024-04-23
201906-1240-001 Reinstatement without change of a previously approved collection 2020-02-12
201705-1240-001 No material or nonsubstantive change to a currently approved collection 2017-05-30 Approved without change
201612-1240-008 No material or nonsubstantive change to a currently approved collection 2017-01-19 Approved without change
201610-1240-004 No material or nonsubstantive change to a currently approved collection 2016-10-31 Approved without change
201606-1240-003 New collection (Request for a new OMB Control Number) 2016-09-06 Approved with change