Information Collection Request
Authorization Request Forms/Certification/Letter of Medical Necessity
ICR 202404-1240-005 · OMB 1240-0055 · Active
⚠️ Notice: This information collection may be outdated. More recent filings for OMB 1240-0055 can be found here:
Forms and Documents
IC Document Collections
| IC ID | Collection | Type | Status | Form |
|---|---|---|---|---|
| 221978 |  CA-27, Authorization Request form and Certification/Letter of Medical Necessity for Opioid Medications |
Form and Instruction | Unchanged | |
| 221978 | CA-27, Authorization Request form and Certification/Letter of Medical Necessity for Opioid Medications |
Form and Instruction | Unchanged | |
| 221977 | CA-26, Authorization Request Form and Certification/Letter of Medical Necessity for Compounded Drugs |
Form | Modified | |
| 221977 | CA-26, Authorization Request Form and Certification/Letter of Medical Necessity for Compounded Drugs |
Form | Modified |
ICR Details
| Status | Active |
|---|---|
| Agency/Subagency | DOL/OWCP |
| OMB Control No | 1240-0055 |
| Type of Information Collection | No material or nonsubstantive change to a currently approved collection |
| Previous ICR Reference No | 201906-1240-001 |
| Date Submitted to OIRA | 2024-04-23 |
| Requested Expiration Date | 1969-12-31 |