Reach Out to Me

1671 W. Main St., Suite A
EL Centro, CA 92243
(760) 336-2500
[email protected]
Mon - Fri: 8:00 AM - 5:00 PM
Sat & Sun: Closed

Fill Out the Form Below

Name(Required)

Phone(Required)

Email(Required)

Message

Phone

This field is for validation purposes and should be left unchanged.

Stephanie Woodward, M.d.

Patient Registration

Patient Name

Address

City , State , Zip

Pharmacy

Home Phone

Work Phone

Cell Phone

Date of Birth

MM slash DD slash YYYY

Age

Single

Married

Other

Sex

Male

Female

Height

Weight

What Are You Being Seen for ?

Employer/school Name & Address

Any Food or Drug Allergies?

Insurance Information:

Primary Insurance

Insurance Name

Policy Holder's Name

Relationship to Patient

Employer

Policy Holder.s Sex

Male

Female

Policy Holder's Date of Birth

MM slash DD slash YYYY

Are You Pregnant ?

Yes

How Were You Referred to Our Office?

Employer

Co-Worker

Relative

Yellow Pages

Walk in

Ins. Provider Book

Other

Secondary Insurance

Insurance Name

Policy Holder's Name

Relationship to Patient

Employer

Policy Holder's Sex

Male

Female

Policy Holder's Date of Birth

MM slash DD slash YYYY

In Case of Emergency, Name & Phone Number of Nearest Relative

Authorization to Release Information: I hereby authorize this physician to release any information required in the course of my examination or treatment to my insurance company and/or to any other provider.

Signed

Date

MM slash DD slash YYYY

Authorization to Pay: I hereby authorize payment directly to the business of this physician for the surgical and-/or medical benefits, if any, otherwise payable to me for services. I understand that I am financially responsible for the charges not covered by my insurance.

Signed

Date

MM slash DD slash YYYY

Stephanie Woodward, M.d. - New Patient Health History

Name

Date of birth

MM slash DD slash YYYY

Today's Date

MM slash DD slash YYYY

Present Illness

Describe Your Present Medical Symptoms

Lisl Any Drugs You Are Allergic to (What Was the Reaction?)

List Your Current Medication (S) (Prescription and Nonprescription Dru8s and Birth Control Pills)

Name

Dosage

How many times/day?

Past Medical History

(1) Surgeries

Date

MM slash DD slash YYYY

Type of Surgery

Which Hospital ?

Surgeon

(2) Previous significant medical problems/hospitalizations

Date

MM slash DD slash YYYY

Type of illness

Where Treated?

Do You Have Any of the Following Illnesses?

Diabetes

Yes

High Blood Pressure

Yes

Lung Disease

Yes

Cancer

Yes

Stroke

yes

Heart Disease

Yes

Anemia

Yes

Any Other Medical Problems.

Yes

Give any details of illness

Family History

Do you have relatives with any of the following illnesses?

Heart Attack (age < 65)

Yes

Ovarian Cancer

Yes

Breast Cancer

Yes

Prostate Cancer

Yes

Colon Cancer

Yes

Any Other Cancer

Yes

Any other Medical Problems

Yes

Relationship/ and Details

Stephanie Woodward, M.d. _ New Patient Health History

Social- History

Marital Status

Occupation

Do you smoke?

How much?

For how Many years?

Do you drink alcohol?

Drinks of wine,beer/hard liquor per day/week

Do you use marijuana?

Cocaine ?

Intravenous drugs?

Do you drink caffeinated beverages ?

How many Cups of Coffee ?

Soda ?

Tea ?

Do you have any risks for HIV exposure ?

NONE

Blood transfusion

IV drug use

Other

Review Of Systems

Do you have any unusual

Fever?

Yes

Night Sweats?

Yes

Chills?

Yes

Fatigue?

Yes

Have you recently gained weight?

Yes

Have you recently lost weight?

Yes

how much ?

how much?

Iieent

Loss of vision?

Yes

Blurry or double vision?

Yes

Sore throat?

Yes

Runny nose?

Yes

Respiratory

Persistent Cough?

Yes

Sputum/Phlegm production?

Yes

Shortness of breath?

Yes

Cardiac

Do you have any chest pain?

Yes

Palpitations?

Yes

Shortness of breath with minimal activity?

Yes

Shortness of breath when Lying flat?

Yes

Swelling of legs?

Yes

Do you have difficulty walking two block?

Yes

Gastrointestinal

Any abdominal pain?

Yes

Nausea?

Yes

Vomiting?

Yes

Diarrhea?

Yes

Constipation?

Yes

Blood in your stool?

Yes

Where ?

Urinary

Too frequent urination ?

Yes

Any burning with urination ?

Yes

Trouble starting urination ?

Yes

Incontinence of urine?

Yes

Any blood in the urine ?

Yes

Any history of STDs ?

Yes

If yes, what kind of STD? (gonorrhea , chlamidya ,syphilis , genital warts , other )

Neurologic

Any unusual headaches?

Yes

Dizziness?

Yes

History of seizures?

Yes

History of syncopal episodes?

Yes

Weakness in the arms?

Yes

Numbness in the alms?

Yes

Weakness in the legs?

Yes

Numbness in the legs?

Yes

Musculoskeletal

Any persistent joint ache?

Yes

Any swelling in joints?

Yes

Where ?

Hematologic

Any history of abnormal bleeding ?

Yes

Any history of excessive bruising ?

Yes

Any history of anemia?

Yes

Skin

Rash?

Yes

Itching?

Yes

Mass or Lesion?

Yes

Other?

Gynecological

(women only)

Date of your Iast menstrual period?

When was your last mammogram?

Do you have any symptoms not described above?

Stephanie Woodward, M.d. - Financial Policy

Thank you for choosing us as your healthcare provider. We are committed to your treatment being Successful. Please understand that payment of your bill is considered part of your treatment. Your clear Understanding of our financial policy is important to our professional relationship. Please talk to our Business manager if you have any questions about our fees or financial policy.

All patients must complete our "Patient Registration Form" prior to seeing the doctor.
Full Payment is due at time of service.
We accept cash, checks, and Visa,/Mastercard,/Discover.

Regarding Insurance

Insurance is a contract between you and your insurance company. We are not a party to this contract You are responsible for the timely payment of your account.
Our practice is contracted with a number of PPO, HMO, and Managed Care network plans. Please see the attached list of most of the major insurance plans we accept. If your insurance company is not listed, please ask the receptionist for more information.

If we accept your insurance, you must pay any co-payments and unmet deductibles at all times of service. Please be aware that some and perhaps all of the services provided may be "non-covered" services and not considered necessary under the Medicare Program and/or other medical insurance. This especially includes services for well care, such as general physicals. If not covered, you will be responsible for payment of these services.

If the reason for your Visit is a work-related iniurv or an accident, please notify the receptionist.

Diagnostic Studies, X-ray and Other Ancillary Services

If any diagnostic studies such as laboratory tests, x-rays, and other ancillary services are required to complete your care, please be aware that these charges are billed directly to you from the facility rendering the care. This is separate from the office charges and may constitute an additional expense for which our office is not responsible.

Missed Appointments

I understand that if I am unable to keep my scheduled appointment time, failure to notify Dr.Woodward 24-hours before my scheduled appointment will result in a $25.00 cancellation fee for office visits and $50.00 cancellation fee for procedures and consultations.

Initials

Thank you for understanding and agreeing to our Financial Policy. Please let us know if you have any questions or concems. I hereby authorize Stephanie Woodward, M.D. to furnish information to the insurance carriers concerning my illness and treatments. I also authorize to Stephanie Woodward, M.D. all payment for medical services rendered to myself or my dependent. I understand that I am responsible for any amount not covered by insurance.

Signature of Patient or Responsible Party

Date

MM slash DD slash YYYY

Stephanie Woodward, M.D

Notice of Privacy Policy and Practices

Introduction

In accordance with the Health Insurance Portability and Accountability Act of 1996 (Known as HIPAA), our practice is required to protect the privacy of your personal health information. This document will provide notice of our privacy policy and practices including your rights and our legal duties concerning your health information and records. Please review this document; you will be asked to sign a form acknowledging your opportunity to review this notice. A copy will be provided to you upon request.

Summary

Since you are a patient who has consented to receive care from the physician and staff of Stephanie Woodward, M.D., the law allows us to use and disclose your medical information for specific purposes. These include uses and disclosures for purposes of treatment, obtaining payment for services, and health care operations which will be explained below. In addition, the law may authorize disclosures for reasons of public health and interest that include disaster relief, law enforcement, and formal judicial and administrative proceedings. With your permission, your medical information may be disclosed to family members and-/or others of your choosing who have involvement of interest in your health status. Any other disclosure will require your written authorization.

You have the following rights that will be respected by this policy:

To examine or receive a copy of your medical record ofcare that had been provide by Stephanie Woodward, M.D., and staff. (1" copy is provided without charge. Additional copies will involve a nominal cost.)
To receive an accounting of the disclosure of your medical medical information that does not involve treatment, payment, or health care operations.
To request a correction or amendment of your medical record
To specify other restrictions on the use and disclosure of medical information.
To request a specific method or avenue in receiving a communication involving confidential information.
To file a formal complaint if you feel that improper use of disclosure occurred.

The entire notice will go into more detail regarding the specific issues involved in this policy. Please review it.

Receipt of Notice of Privacy Policy and Practices

I acknowledge that I have received or have been given the opportunity to review a copy of

Notice of Privacy Policy and Practices.

I understand that amendment to this policy may occur in the future and that a current summary of this or the amended notice will be posted in the medical office for my review. A copy of the amended notice will be made available upon request.

Print Name

Date

MM slash DD slash YYYY

Signature

Relationship to Patient (if other than patient)

Notice to Patients about Open Pavments Database

"The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. it can be found at https://openpaymentsdata.cms.gov."

Your signature below constitutes your acknowledgment,

Print Name

Date

MM slash DD slash YYYY

Signature

Relationship to Patient (if other than patient)

This field is for validation purposes and should be left unchanged.

Notice to Patients about Open Pavements Database Patient Copy

"The Open Payments database is a federal tool used to search
payments made by drug and device companies to physicians
and teaching hospitals. it can be found at
https://openpavmentsdata.cms.gov."

Stephanie Woodward, M.d. Inc

Patient Registration

Patient Name

Address

City , State , Zip

Pharmacy

Home Phone

Work Phone

Cell Phone

Date of Birth

MM slash DD slash YYYY

Age

Single

Married

Other

Sex

Male

Female

Height

Weight

What Are You Being Seen for ?

Employer/school Name & Address

Any Food or Drug Allergies?

Insurance Information:

Primary Insurance

Insurance Name

Policy Holder's Name

Relationship to Patient

Employer

Policy Holder.s Sex

Male

Female

Policy Holder's Date of Birth

MM slash DD slash YYYY

Are You Pregnant ?

Yes

How Were You Referred to Our Office?

Employer

Co-Worker

Relative

Yellow Pages

Walk in

Ins. Provider Book

Other

Secondary Insurance

Insurance Name

Policy Holder's Name

Relationship to Patient

Employer

Policy Holder's Sex

Male

Female

Policy Holder's Date of Birth

MM slash DD slash YYYY

In Case of Emergency, Name & Phone Number of Nearest Relative

Signed

Date

MM slash DD slash YYYY

Signed

Date

MM slash DD slash YYYY

Stephanie Woodward, M.d. - New Patient Health History

Name

Date of birth

MM slash DD slash YYYY

Today's Date

MM slash DD slash YYYY

Present Illness

Describe Your Present Medical Symptoms

Lisl Any Drugs You Are Allergic to (What Was the Reaction?)

List Your Current Medication (S) (Prescription and Nonprescription Dru8s and Birth Control Pills)

Name

Dosage

How many times/day?

Past Medical History

(1) Surgeries

Date

MM slash DD slash YYYY

Type of Surgery

Which Hospital ?

Surgeon

(2) Previous significant medical problems/hospitalizations

Date

MM slash DD slash YYYY

Type of illness

Where Treated?

Do You Have Any of the Following Illnesses?

Diabetes

Yes

High Blood Pressure

Yes

Lung Disease

Yes

Cancer

Yes

Stroke

yes

Heart Disease

Yes

Anemia

Yes

Any Other Medical Problems.

Yes

Give any details of illness

Family History

Do you have relatives with any of the following illnesses?

Heart Attack (age < 65)

Yes

Ovarian Cancer

Yes

Breast Cancer

Yes

Prostate Cancer

Yes

Colon Cancer

Yes

Any Other Cancer

Yes

Any other Medical Problems

Yes

Relationship/ and Details

Stephanie Woodward, M.d. _ New Patient Health History

Social- History

Marital Status

Occupation

Do you smoke?

How much?

For how Many years?

Do you drink alcohol?

Drinks of wine,beer/hard liquor per day/week

Do you use marijuana?

Cocaine ?

Intravenous drugs?

Do you drink caffeinated beverages ?

How many Cups of Coffee ?

Soda ?

Tea ?

Do you have any risks for HIV exposure ?

NONE

Blood transfusion

IV drug use

Other

Review Of Systems

Do you have any unusual

Fever?

Yes

Night Sweats?

Yes

Chills?

Yes

Fatigue?

Yes

Have you recently gained weight?

Yes

Have you recently lost weight?

Yes

how much ?

how much?

Iieent

Loss of vision?

Yes

Blurry or double vision?

Yes

Sore throat?

Yes

Runny nose?

Yes

Respiratory

Persistent Cough?

Yes

Sputum/Phlegm production?

Yes

Shortness of breath?

Yes

Cardiac

Do you have any chest pain?

Yes

Palpitations?

Yes

Shortness of breath with minimal activity?

Yes

Shortness of breath when Lying flat?

Yes

Swelling of legs?

Yes

Do you have difficulty walking two block?

Yes

Gastrointestinal

Any abdominal pain?

Yes

Nausea?

Yes

Vomiting?

Yes

Diarrhea?

Yes

Constipation?

Yes

Blood in your stool?

Yes

Where ?

Urinary

Too frequent urination ?

Yes

Any burning with urination ?

Yes

Trouble starting urination ?

Yes

Incontinence of urine?

Yes

Any blood in the urine ?

Yes

Any history of STDs ?

Yes

If yes, what kind of STD? (gonorrhea , chlamidya ,syphilis , genital warts , other )

Neurologic

Any unusual headaches?

Yes

Dizziness?

Yes

History of seizures?

Yes

History of syncopal episodes?

Yes

Weakness in the arms?

Yes

Numbness in the alms?

Yes

Weakness in the legs?

Yes

Numbness in the legs?

Yes

Musculoskeletal

Any persistent joint ache?

Yes

Any swelling in joints?

Yes

Where ?

Hematologic

Any history of abnormal bleeding ?

Yes

Any history of excessive bruising ?

Yes

Any history of anemia?

Yes

Skin

Rash?

Yes

Itching?

Yes

Mass or Lesion?

Yes

Other?

Gynecological

(women only)

Date of your Iast menstrual period?

When was your last mammogram?

Do you have any symptoms not described above?

Stephanie Woodward, M.d. - Financial Policy

All patients must complete our "Patient Registration Form" prior to seeing the doctor.
Full Payment is due at time of service.
We accept cash, checks, and Visa,/Mastercard,/Discover.

Regarding Insurance

If the reason for your Visit is a work-related iniurv or an accident, please notify the receptionist.

Diagnostic Studies, X-ray and Other Ancillary Services

Missed Appointments

Initials

Signature of Patient or Responsible Party

Date

MM slash DD slash YYYY

Stephanie Woodward, M.D

Notice of Privacy Policy and Practices

Introduction

Summary

You have the following rights that will be respected by this policy:

To examine or receive a copy of your medical record ofcare that had been provide by Stephanie Woodward, M.D., and staff. (1" copy is provided without charge. Additional copies will involve a nominal cost.)
To receive an accounting of the disclosure of your medical medical information that does not involve treatment, payment, or health care operations.
To request a correction or amendment of your medical record
To specify other restrictions on the use and disclosure of medical information.
To request a specific method or avenue in receiving a communication involving confidential information.
To file a formal complaint if you feel that improper use of disclosure occurred.

The entire notice will go into more detail regarding the specific issues involved in this policy. Please review it.

Receipt of Notice of Privacy Policy and Practices

I acknowledge that I have received or have been given the opportunity to review a copy of

Notice of Privacy Policy and Practices.

Print Name

Date

MM slash DD slash YYYY

Signature

Relationship to Patient (if other than patient)

Notice to Patients about Open Pavments Database

"The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. it can be found at https://openpaymentsdata.cms.gov."

Your signature below constitutes your acknowledgment,

Print Name

Date

MM slash DD slash YYYY

Signature

Relationship to Patient (if other than patient)

Phone

This field is for validation purposes and should be left unchanged.

Patient Registration Forms

Notice to Patients about Open Pavements Database Patient Copy

"The Open Payments database is a federal tool used to search
payments made by drug and device companies to physicians
and teaching hospitals. it can be found at
https://openpavmentsdata.cms.gov."