Erectoral 2026

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The document is a CIGNA HealthCare Prior Authorization Form for erectile dysfunction medications. It outlines the necessary provider and patient information required for processing, including medication requests, diagnosis details, and specific questions regarding the patient's condition. The form emphasizes the importance of completing all sections to avoid delays or adverse determinations and provides contact information for submission and inquiries.

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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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