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Airship Electrolysis Intake Form

Welcome to Airship Electrolysis! We're excited to book your first session, but we need to get to know you first.

First Name *

Last Name *

Preferred name (if different from legal name)

Pronouns *

Email *

Phone *

How did you find us?

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Please read the following information about insurance before selecting your answers below.

If you have private insurance, we can provide a superbill to submit for reimbursement. If you require a prior auth or gap exception, or feel uncertain about the superbill process, let us know and we can help. You will be responsible for the up-front costs of sessions, but our team is available to assist you through the reimbursement process.

Kaiser patients are only responsible for their Kaiser co-pays. You must provide your Kaiser card, front and back, and your driver's license or state ID, before booking your first session. If you are prepping for surgery, you may also require a referral from your Kaiser PCP or surgeon.

If you have Medi-cal, please provide your insurance card and any other relevant info about your plan and medical need for electrolysis (such as a gender dysphoria diagnosis, doctor's letter, or surgery date). We won't be able to offer you immediate coverage but we will work towards getting you a single-case agreement for future coverage.

We are working towards achieving in-network relationships with various Medi-cal plans, including Alameda Alliance, SFHP, and Partnership. Currently, we can work with Medi-cal members insured through North East Medical Services at no up-front cost to the patient.

Are you using insurance?

Yes

No

Unsure

How do you plan to pay for your sessions?

I have private insurance. I will pay up front and submit a superbill for reimbursement.

I plan to pay out-of-pocket. I will not be using insurance.

I'm a Kaiser patient. I plan to pay my Kaiser co-pay.

I'm a Medi-cal patient. I want to get a single-case agreement.

I'm insured through North East Medical Services. I can provide my insurance card to verify coverage.

I want to use insurance, but first I need help understanding my options or submitting documentation.

What insurance do you have (provider name & plan)?

These are our prices for private insurance and out-of-pocket payment. If you require a prior auth, gap exception, or SCA, or feel uncertain about the superbill process, our team can assist you. However, you can only book a session when you are ready to move forward with payment.

Private insurance prices:

$200/hour - Face / Body

$250/hour - Lower Body / Surgery prep

Out-of-pocket prices:

$170/hour - Face / Body

$220/hour - Lower Body / Surgery Prep

Are you ready to book your first session?

I understand the payment process. I'm ready to book.

I still have questions about payment. I want to talk to the office team.