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Department of Dermatology
Anheuser Busch Institute
1755 South Grand Blvd
St. Louis, MO 63104
(314) 256-3420
(866) 977-4440
FAX (314) 256-3421
Department of Dermatology
Des Peres Medical Arts Pavilion II
2315 Dougherty Ferry Rd., Suite 200A
St. Louis, MO 63122
(314) 977-9721
(866) 977-4440
FAX (314) 977-9725
SLUCare welcomes you to the Department of Dermatology Mohs’ Unit. We are looking
forward to meeting with you and caring for your skin problem.
Because of the recent insurance demands, we are required to have patients provide
referral and/or authorizations for office visits as needed and approvals for biopsies and
other procedures that may occur during your office visit with us.
Even if you have had a previous biopsy, it is very important to get prior authorization for
further treatments if needed. We want to provide you with the care you need in a timely
manner.
Information needed:
 Primary Insurance Company__________________________________________
Phone#__________________
Policy #_______________________Member ID #_______________________________
HMO___ PPO____ POS____
1) Evaluation and Treatment Authorization#__________________________
2) Approval for 3-office visits________________
 Secondary Insurance Company_________________________________________
Policy #____________________________________
HMO____
Please bring this information to your appointment with us.
If you are unable to acquire this authorization before your scheduled office visit, we will
be able to retrieve this information, but this lack of insurance information may delay your
care by the Department of Dermatology on the day of your appointment, or postpone
needed procedures on your appointment day. Treatment will need to be rescheduled
when proper insurance authorization is available.
If postponing is needed, we will be glad to reschedule needed procedures to another time.
Thank you for your help,
SLUCare Department of Dermatology