Erectoral 2026

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01. Edit your erectoral online
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Click ‘Get Form’ to open the erectoral in the editor.
Begin by filling out the Provider Information section. Enter your name, specialty, DEA or TIN, office contact person, and office phone number.
Next, complete the Patient Information section. Input the patient's name, CIGNA ID, date of birth, and contact details including phone number and address.
In the Medication Requested field, select the appropriate erectile dysfunction medication from the list provided. Ensure you specify dosage if applicable.
Indicate the diagnosis related to use by checking the relevant box for Erectile Dysfunction or PAH. If applicable, provide additional details such as ICD-9 codes.
Finally, review all entries for accuracy before submitting. Once completed, fax the form to (800)390-9745 using our platform's secure sending feature.

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