† Lines are open 8am to 6pm Monday to Friday, and 8am to 4pm Saturday. We may record or monitor our calls.

To pre-authorise funding for Bupa patients, we’d be grateful if you could: Complete every section of this form so we can assess whether treatment is eligible for funding under our customers’ health insurance schemes. We’ll let you know within three working days of receiving your completed form. If we need to ask for more information, it’s likely to delay our funding decision and the patient’s treatment. � Please tick here if you need an urgent response Type on the form, rather than handwriting it, and return it by secure email: policyreviewerskinlesions@bupa.com or fax: 01784 234 295. Please be aware that information you send to this email address may not be secure unless you send us your email through Egress Switch. For more information and to sign up for a free Egress Switch account, go to https://switch.egress.com/ui/learn. You won’t be charged for sending secure emails to a Bupa email address using the Switch service.

If you’ve any questions, please call us on: 0161 873 9024*.

Patient and consultant information: Patient’s name: Consultant’s name: Date of birth: Bupa Provider Number: Bupa Membership Number: Phone number:

History of the patient’s lesion: Where is the lesion situated?

Please tick history: � crust

� newly appeared � change in shape � itch / soreness

� change in size � change in colour � bleeding

Risk factors: Previous medical history of skin cancer(s) removed:

Family history of cancer?

Skin type? Number of blistering sunburns?

Please tick sun exposure history: � occupation

� sunbathe/sunbeds � outdoor hobbies � residence/travel abroad

Personal medical history:

Pacemaker? � Yes � No Defibrillator? � Yes � No

Drug history: Anticoagulants? � Yes � No Immunosuppressants? � Yes � No

Does the patient have any allergies? � Yes � No

Pre-authorisation: Minor skin lesion procedures

2 May 2016

Examination:

Description:

Size:

Dermoscopy:

Full skin check? � Yes � No Findings:

Diagnosis: Management plan:

� Reassurance � Self monitor � Refer to GP

� Procedure (please complete ‘reason for procedure’ section below)

Procedure code(s):

Reason for procedure (please tick all that apply):

� Diagnosis - urgent (malignant melanoma/ squamous cell carcinoma)

� Diagnosis – standard (basal cell carcinoma/pre-malignant)

� Other clinical reason – please provide details:

Please note that our customers’ policies don’t cover any removal of skin without symptoms, ie for cosmetic reasons.

ONLY COMPLETE FOR SAME DAY PROCEDURES (retrospective funding requests) Action taken: � Excision � Diagnostic/incisional/punch biopsy � Shave biopsy Histopathology results:

Procedure notes: For your records only (not necessary for funding eligibility) Date: Surgeon:

Consent: � written � verbal Local anaesthetic type: � Lidocaine 1%/2% � + adrenaline

Site: Type of procedure:

Closure: Removal of sutures: Dressing:

Follow up required: � Write with results � Follow up appointment

Declaration:

Please complete this section to confirm that the information in this form is accurate to the best of your knowledge, and that the patient (or their representative) has given permission for this information to be shared with us.

Consultant’s name:

General Medical Council number: Date: