Authorization Request Forms/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-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
Form CA-26 CA-26, Authorization Request Form and Certification/Letter of Medical Necessity for Compounded Drugs Form
Justification CA-26_MN_4.26.24 amended clean.docx Justification for No Material/Nonsubstantive Change
Supporting Statement 1240-0055_1.14.2020.docx Supporting Statement A
Supporting Statement 1240-0055 - EC_MN2 nonsub 4.22.2024 - EC clean.docx Supporting Statement A
Justification CA-26_MN 4.22.2024_OWCP Approved.docx Justification for No Material/Nonsubstantive Change
Justification CA-26_MN 4.22.2024_OWCP Approved.docx Justification for No Material/Nonsubstantive Change
CA 26 LMN Compounded Drugs - highlighted change areas.pdf Supplementary Document
CA 26 LMN Compounded Drugs - highlighted change areas.pdf Supplementary Document
Privacy Act Systems-FECA.docx Supplementary Document
Privacy Act Systems-FECA.docx Supplementary Document
OPM Salary Table 2019.pdf Supplementary Document
OPM Salary Table 2019.pdf Supplementary Document
Physicians and Surgeons, All Other occupational employment and wages 2018.htm Supplementary Document
Physicians and Surgeons, All Other occupational employment and wages 2018.htm Supplementary Document
CA-27, Authorization Request form and Certification/Letter of Medical Necessity for Opioid Medications Form and Instruction
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
CA-26, Authorization Request Form and Certification/Letter of Medical Necessity for Compounded Drugs Form