Patient Forms

Segel Podiatry is not taking new patients at this time.

For new patients already scheduled or established patients that have not been seen for more than 3 years, please print, and fill out the documents below.

pdfNotice of Privacy Practice (HIPPA)

pddfNew Patient Intake Form

  • Please download, print and fill out both forms below.
  • Patient form must be filled out by the patient or the caregiver.

  • Please bring those completed forms, with a copy of your insurance cards before your appointment or fax it back to 877.559.7725

  • Patients younger than 18 years of age must be accompanied by their parents or guardian.
  • For those of you who need referrals (HMO plans), please contact your primary care doctors to obtain the approval.

    Our fax is 877.559.7725.

Note To Medicaid Patients:

Medicaid only covers Podiatric services when referred by your Primary Doctor and when the treatment sited in the written referral is for the “life and safety” of the patient. These are their rules, not ours !

Note To Blue Cross Blue Shield, Harvard Pilgrim and NHP Patients:

Please check your plan to see if you need a referral from your Primary Care Physician.

Note To Wampanoag Tribal Health Members:

Please call the Tribal Health Program and let them know of your upcoming appointment so they can issue an authorization number.