Information Collection Request
Authorization Request Form/Certification/Letter of Medical Necessity
ICR 202405-1240-002 · OMB 1240-0055 · Received in OIRA
Forms and Documents
| Document | Type | Status | Availability |
|---|---|---|---|
 Form CA-27 CA-27, Authorization Request form and Certification/Letter of Medical Necessity for Opioid Medications |
Form and Instruction | Modified | Repair queued |
| Form CA-26 CA-26, Authorization Request Form and Certification/Letter of Medical Necessity for Compounded Drugs |
Form | Removed | Repair queued |
 60 day FRN.corrected for 1240-055 03.26.2024.pdf |
Supplementary Document | Uploaded 2024-05-06 | Repair queued |
| 60 day FRN for 1240-0055. published 01.26.2024.pdf |
Supplementary Document | Uploaded 2024-05-06 | Repair queued |
 Privacy Act Systems-FECA.docx |
Supplementary Document | Uploaded 2024-05-06 | Repair queued |
| OPM 2024 Salary Table.pdf |
Supplementary Document | Uploaded 2024-05-06 | Repair queued |
| Physians And Surgeons, All Other Occupational Employment And Wages 2022.pdf |
Supplementary Document | Uploaded 2024-05-06 | Repair queued |
| Supporting Statement 1240-0055.updated 20240506_MN.clean copy.docx |
Supporting Statement A | Uploaded 2024-05-07 | Repair queued |
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 | Modified | |
| 221977 | CA-26, Authorization Request Form and Certification/Letter of Medical Necessity for Compounded Drugs |
Form | Removed |
ICR Details
| Status | Received in OIRA |
|---|---|
| Agency/Subagency | DOL/OWCP |
| OMB Control No | 1240-0055 |
| Type of Information Collection | Revision of a currently approved collection |
| Previous ICR Reference No | 202404-1240-005 |
| Date Submitted to OIRA | 1969-12-31 |
| Requested Expiration Date | 1969-12-31 |