McKnight Pediatrics
202-291-6257
info@mcknightpediatrics.com
106 Irving St NW Ste 2300
Washington, Washington D.C. 20010
mcknightpediatrics.com

Thank you for taking the time to participate in our developmental screening and monitoring program.  The development of your child is very important to us and we ask that you complete the survey for your child prior to each well visit so we may monitor and discuss your child's progress during their appointment.  Please complete the questionnaires online and do not print it out so that it may be graded prior to your appointment  If you have any questions or concerns please bring them with you to the visit.

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Because your child's first 5 years of life are so important, we want to help you provide the best start for your child. You've been invited to participate in the Ages & Stages Questionnaires, Third Edition (ASQ-3), to help you keep track of your child's development. The questionnaire may be provided every 2-, 4- or 6-month period. You will be asked to answer questions about some things your child can and cannot do. The questionnaire includes questions about your child's communication, gross motor, fine motor, problem solving, and personal social skills.

Please enter your child's birth date and the number of weeks he or she was born premature below to start the screening. Please note that the information you enter into this website is secure and cannot be seen or accessed by anyone other than the program employees who have invited you to participate in this screening.

We look forward to your participation in ASQ-3!



(put "0" if not premature)

Patient Consent for Use and Disclosure 

of Protected Health Information

 

 

I hereby give my consent for Marjorie B. McKnight, M.D, PC to use and disclose

protected health information (PHI) about me to carry out treatment, payment and health care operations (TPO). 

(The Notice of Privacy Practices provided by Marjorie B. McKnight, M.D, PC describes such uses and disclosures more completely.) 

 

I have the right to review the Notice of Privacy Practices prior to signing this consent. 

Marjorie B. McKnight, M.D, PC reserves the right to revise its Notice of Privacy Practices

at any time. A revised Notice of Privacy Practices may be obtained by forwarding a 

written request to Doretha Carroll at 106 Irving St NW Suite 2300, Washington, DC 20010.

 

With this consent, Marjorie B. McKnight, M.D, PC may call my home or other alternative location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory test results, among others. 

 

With this consent, Marjorie B. McKnight, M.D, PC may mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked ?Personal and Confidential.? 

 

With this consent, Marjorie B. McKnight, M.D, PC may e-mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that Marjorie B. McKnight, M.D, PC restrict how it uses or discloses my PHI to carry out TPO. The practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement. 

 

By signing this form, I am consenting to allow Marjorie B. McKnight, M.D, PC to use and disclose my PHI to carry out TPO. 

 

I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, Marjorie B. McKnight, M.D, PC may decline to provide treatment to me.

Note: By clicking "Submit", you are agreeing to both our Family Access End User License Agreement and any other consent or authorization information outlined on this page.