Authorization Request Form/Certification/Letter of Medical Necessity

OMB 1240-0055

Latest Forms, Documents, and Supporting Material

Document Name
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