OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Authorization Request Forms/Certification/Letter of Medical Necessity

ICR 201606-1240-003 · OMB 1240-0055 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form CA-27 CA-27, Authorization Request form and Certification/Letter of Medical Necessity for Opioie Medications Form and Instruction New Repair queued
Form CA-26 CA-26, Authorization Request Form and Certification/Letter of Medical Necessity for Compounded Drugs Form and Instruction New Repair queued
OMB_Response to September 16 notice_10052016.pdf Supplementary Document Uploaded 2016-10-13 Available
2016 09 14 PMG letter to Thomas E Perez Secretary of Labor re Uncontroll....pdf Supplementary Document Uploaded 2016-10-13 Available
Response to Postal Comment and House Letter.docx Supplementary Document Uploaded 2016-10-12 Available
OPM Salary Table 2016-RUS.pdf Supplementary Document Uploaded 2016-06-15 Available
BLS OES Salary Table for Physicians May 2015.docx Supplementary Document Uploaded 2016-06-15 Repair queued
Privacy Act Systems.doc Supplementary Document Uploaded 2016-06-15 Available
Supporting Statement 1240-XXXX FOR AUTHORIZATION FORMS FOR LETTER OF AUTHORIZATION-MEDICAL NECESSITY FOR PRESCRIPTIONS October 2016.docx Supporting Statement A Uploaded 2016-10-12 Available
IC Document Collections
IC IDCollectionTypeStatusForm
221978 CA-27, Authorization Request form and Certification/Letter of Medical Necessity for Opioie Medications Form and Instruction New
221977 CA-26, Authorization Request Form and Certification/Letter of Medical Necessity for Compounded Drugs Form and Instruction New
ICR Details
1240-0055 201606-1240-003
Historical Active
DOL/OWCP
Authorization Request Forms/Certification/Letter of Medical Necessity
New collection (Request for a new OMB Control Number)   No
Regular
Approved with change 10/13/2016
Retrieve Notice of Action (NOA) 09/06/2016
  Inventory as of this Action Requested Previously Approved
10/31/2019 36 Months From Approved
170,000 0 0
85,000 0 0
0 0 0
The forms, Authorization Request Form and Certification/Letter of Medical Necessity for Compounded Drugs (CA-26) and Authorization Request Form and Certification/Letter of Medical Necessity Certification/Letter of Medical Necessity for Opioid Medications (CA-27), require an injured worker’s treating physician to answer a number of questions about the prescribed opioids and/or compounded drugs and certify that they are medically necessary to treat the work-related injury. The responses to the questions on the forms are intended to ensure that treating physicians have considered non-opioid and non-compounded drug alternatives, and are only prescribing the most cost effective and medically necessary drugs. The forms will also permit OWCP to more easily track the volume, type, and characteristics of opioids and compounded drugs authorized by the FECA program. The forms will serve as a means for injured workers to continue receiving opioids and compounded drugs only where medically necessary and simultaneously give OWCP greater oversight in monitoring their appropriate use and gather additional data about their use.
US Code: 5 USC 8103 Name of Law: Federal Employees' Comensation Act
   US Code: 5 USC 8145 Name of Law: Federal Employees' Comensation Act
   US Code: 5 USC 8124 (a) (2) Name of Law: Federal Employees' Comensation Act
   US Code: 5 USC 8149 Name of Law: Federal Employees' Comensation Act
  
None
Not associated with rulemaking
  81 FR 40721 06/22/2016
81 FR 61255 09/06/2016
Yes
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 170,000 0 0 170,000 0 0
Annual Time Burden (Hours) 85,000 0 0 85,000 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
This is a new collection.
$17,818,719
No
No
No
No
No
Uncollected
Marcus Sharpless 202 693-0998 [email protected]
  No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
09/06/2016