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
| Document | Type |
|---|---|
 Form CA-27 CA-27, Authorization Request form and Certification/Letter of Medical Necessity for Opioid Medications | Form and Instruction |
| Form CA-26 CA-26, Authorization Request Form and Certification/Letter of Medical Necessity for Compounded Drugs | Form |
 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.docx | Supporting Statement A |
 CA-27, Authorization Request form and Certification/Letter of Medical Necessity for Opioid Medications |
Form and Instruction |
| CA-26, Authorization Request Form and Certification/Letter of Medical Necessity for Compounded Drugs |
Form |
All Historical Document Collections
| Reference | Filing | Received | Concluded | Action |
|---|---|---|---|---|
| 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 |