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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
CA-27, Authorization Request form and Certification/Letter of Medical Necessity for Opioid Medications
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
20 CFR 10.310
20 CFR 10.800
20 CFR 10.809
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form and Instruction
CA-27
Authoriization/Request Form and Certification/Letter of Medical Necessity for Opioid Medications
CA 27 LMN Opioids.pdf
Yes
Yes
Fillable Printable
Instruction
CA 27 LMN Opioids Instructions.pdf
Yes
Yes
Fillable Fileable Signable
Form and Instruction
CA-27 (Web)
Authorization Request form and Certification/Letter of Medical Necessity for Opioid Medications
CA-27 LMNOpioid-UAT with Burden Statement.PNG
Yes
Yes
Fillable Fileable Signable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
DOL/GOVT-1
FR Citation:
81 FR 47418
Number of Respondents:
45,100
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
100 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
45,100
0
0
-109,400
154,500
0
Annual IC Time Burden (Hours)
22,550
0
0
-54,700
77,250
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
No associated records found
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.