OMB.report

Federal forms, ICRs, and supporting documents

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 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

All Historical Document Collections

202405-1240-002 Approved with change	Revision of a currently approved collection	2024-05-30
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 Approved without change	No material or nonsubstantive change to a currently approved collection	2017-05-30
201612-1240-008 Approved without change	No material or nonsubstantive change to a currently approved collection	2017-01-19
201610-1240-004 Approved without change	No material or nonsubstantive change to a currently approved collection	2016-10-31
201606-1240-003 Approved with change	New collection (Request for a new OMB Control Number)	2016-09-06