13 835a form 2026

1. Click ‘Get Form’ to open the 13 835a form in the editor.
2. Begin by entering the organization name in the 'Org' field, indicating whether this is a request for authorization or reimbursement adjustment.
3. In the 'Authorization Type' section, specify if this is a new request or an update by selecting either '1' for New or '2' for Update.
4. Fill in the client's name and Client ID, ensuring all required fields are completed accurately.
5. For updates, enter the previous authorization number in the 'Reference Auth #' field.
6. Complete the provider information by entering the Pharmacy NPI # and fax number, as well as Prescriber details including NPI #, specialty, phone, and fax numbers.
7. Specify the date of fill and indicate if it was signed ‘Dispense as Written’ (Yes/No).
8. Detail the drug name, strength, form, actual per unit cost, AWP per unit cost, RX#, wholesaler information, product ID, quantity requested, days supply, and directions for use (SIG).
9. Lastly, provide any medical information such as diagnosis code and name along with patient residence details and additional comments if necessary.

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