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PLEASE COMPLETE ALL THE ENCLOSED INFORMATION BEFORE ARRIVING FORYOUR APPOINTMENT.NOTE THAT YOU MAY BE DILATED AT EVERY VISIT, THEREFORE IT IS ALWAYSRECOMMENDED THAT YOU BRING A DRIVER.Dear Patient:We would like to welcome you to Southeastern Retina Associates. Please visit our website(www.southeasternretina.com) for more information about our practice, physicians, and variouslocations in Tennessee, and the surrounding states.Thorough retinal evaluation requires that you spend more time in our office than would benecessary for a general eye examination. During the initial visit, we will ask you questions aboutyour eyes, your general health, and any medications that you take. Collection of medical informationand a variety of tests must be performed both before and after dilation of the pupils. Please bring acompanion to drive you home after the dilated eye exam.Please remember that traffic and parking can add to delays at some of the different locations, soconsider allowing for additional travel time. If you discover that you are going to be late, please callus as soon as possible. We do understand unforeseeable delays may occur. We will try toaccommodate the patients who are late, but please understand this may not always be possiblewithout compromising the quality of your care and depriving other patients of their own scheduledappointment times.Thank you,Southeastern Retina AssociatesAppointment Date:Appointment Time:Appointment Location:

Diseases and Surgery of the Retina and Vitreous Ǥ ǡ Ǥǡ Ǥ Ǥ Ǥ ǡ Ǥǡ Ǥ Ǥ Ǥ ǡ Ǥ Ǥ Ǥ ǡ Ǥ Ǥ Ǥ ǡ Ǥ Ǥ Ǥ ǡ Ǥ Ǥ Ǥ ǡ Ǥ Ǥ Ǥ ǡ Ǥ Ǥ Ǥ ǡ Ǥ Ǥ ǡ Ǥ Ǥ Ǥ ǡ Ǥǡ Ǥ Ǥ ǡ Ǥ Ǥ Ǥ ǡ Ǥ Ǥ ǡ Ǥ Ǥ Ǥ ǡ Ǥ Ǥ John C. Hoskins, M.D., Emeritus FINANCIAL POLICY, updated June, 2019 ȋ Ȍ Ǥ Ǥ ȋ Ȍ Ǥ Ǥ Ǥ ǯ Ǥ x We ask that you bring your insurance card(s) with you to each visit. ǡ Ǥ ǡ Ǥ x Any copay, coinsurance or deductible required by your insurance company must be paid at the time services are rendered. ǡ ǡ ǡ ǡ ǡ ǡ Ǥ Ultimately your bill is your financial responsibility. x It is common for our patients to require injection therapy for the conditions we treat. These treatments are expensive, and can result in significant outǦofǦpocket expenses, particularly if you do not maintain careful attention to your available benefits and follow through with the necessary paperwork and protocolsǤ ǡ you are ultimately responsible for the cost of the care you receive. x SERA will file your primary, secondary and tertiary insurance plans. ǡ ǡ ǡ ǡ Ǥ Ǥ ǡ ǯ Ǥ Ǥ x Medicare patients in temporary care of a Skilled Nursing Facility (“SNF”) have restrictions on services provided by our physicians as the SNF is responsible for your care while admitted to their facility. ǯ Ǥ prior Ǥ Ǥ Chattanooga/N Georgia ͳ Ͳͷ ǡ ͓ʹͲͳ ǡ Ͷ Phone: (423) 756Ǧ1002 ǣ ȋͶʹ Ȍ ͷ ǦͳͲͲͶ Greater Knoxville Area ͳͳʹͶ ǡ ͓ʹͲ ǡ ͻͲͻ Phone: (865) 588Ǧ0811 ǣ ȋͺ ͷȌ ͻ ͶǦ ͺͻʹ TriǦCities/Virginia ʹͶͳʹ Ǥ ǡ Ͳ Phone: (423) 578Ǧ4364 ǣ ȋͶʹ Ȍ ͷ ͺǦͶ ʹ Ǥ Ǥ Corporate offices ʹͲ Ǥ ǡ ͻʹ Phone: (865) 934Ǧ3891 ǣ ȋͺ ͷȌ ͻ ͶǦ ͺͻʹ Billing ͷͺͳͻ ǡ ͓ͳͳ ǡ Ͷ Phone: (423) 756Ǧ1512 ǣ ȋͶʹ Ȍ ͶͺǦͲͷʹͷ

Diseases and Surgery of the Retina and Vitreous Ǥ ǡ Ǥǡ Ǥ Ǥ Ǥ ǡ Ǥǡ Ǥ Ǥ Ǥ ǡ Ǥ Ǥ Ǥ ǡ Ǥ Ǥ Ǥ ǡ Ǥ Ǥ Ǥ ǡ Ǥ Ǥ Ǥ ǡ Ǥ Ǥ Ǥ ǡ Ǥ Ǥ Ǥ ǡ Ǥ Ǥ ǡ Ǥ Ǥ Ǥ ǡ Ǥǡ Ǥ Ǥ ǡ Ǥ Ǥ Ǥ ǡ Ǥ Ǥ ǡ Ǥ Ǥ Ǥ ǡ Ǥ Ǥ John C. Hoskins, M.D., Emeritus x Uninsured (SelfǦPay) patients are required to pay in full at the time of service Ǥ ǡ Ǥ ǡ Ǥ Any discounted fee must be paid in full at the time of service. x Outside collection agency assistance may be pursued if your balance remains unpaid for 60 days after the date of service. x Financial Hardship Assistance Ǥ ǯ Ǥ ǡ ǡ ǡ Ǥ Ǥ Any discounted fee must be paid in full at the time of service. x You will incur a fee of 25 for completion of various forms (disability, FMLA, etc.) as well as a request for copies of your medical records. Ȁ Ǥ x An additional fee of 30 may be incurred for any returned check from your banking institution. Our Corporate Billing Office can be reached at 423Ǧ756Ǧ1512. By signing below, I acknowledge receipt and understanding of the Southeastern Retina Associates Financial Policy. Chattanooga/N Georgia ͳ Ͳͷ ǡ ͓ʹͲͳ ǡ Ͷ Phone: (423) 756Ǧ1002 ǣ ȋͶʹ Ȍ ͷ ǦͳͲͲͶ Greater Knoxville Area ͳͳʹͶ ǡ ͓ʹͲ ǡ ͻͲͻ Phone: (865) 588Ǧ0811 ǣ ȋͺ ͷȌ ͻ ͶǦ ͺͻʹ TriǦCities/Virginia ʹͶͳʹ Ǥ ǡ Ͳ Phone: (423) 578Ǧ4364 ǣ ȋͶʹ Ȍ ͷ ͺǦͶ ʹ Ǥ Ǥ Corporate offices ʹͲ Ǥ ǡ ͻʹ Phone: (865) 934Ǧ3891 ǣ ȋͺ ͷȌ ͻ ͶǦ ͺͻʹ Billing ͷͺͳͻ ǡ ͓ͳͳ ǡ Ͷ Phone: (423) 756Ǧ1512 ǣ ȋͶʹ Ȍ ͶͺǦͲͷʹͷ

Patient DemographicsWhich doctor are you seeing today?Patient’s Name: Responsible Party:Address: Zip: City: State:Sex: Male FemaleTitle Mr. Mrs. Miss OtherPhone: Home - - Work - - Cell - -Please check the box for the phone number above that you would like us to use as your primary contact.E-mail: Marital Status:Date Of Birth: / / Single Married Divorced Widow UnknownSocial Security # - - Employer:Emergency Contact: Relationship: Phone:Patient's Employer: Primary Insurance Name:If you have insurance through someone else:Subscriber Name: Subscriber Date of Birth / /Subscriber's Employer:What Physician referred you to us? NAME & ADDRESS:Primary Care Physician? NAME & ADDRESS:Responsible Party if patient is a Minor:Name: Address: Phone: - -Relationship: Date of Birth: / /SSN: - -Employer: Work Phone: Cell:Spouse’s Name:Spouse’s SSN#:Spouse’s Employer: Spouse’s Work Phone:Spouse’s Date of Birth: / /Is your visit related to an accident? Yes NoSpouse’s Cell Phone:Will this be covered under Worker’s Compensation? Yes NoI authorize the disclosure of my personal health information to my referring physician, primary care physician, and insurance company, if applicable, via the use of written or faxtransmittal, to carry out treatment, payment, or health care operations (TPO). I accept full financial responsibility for services rendered by Southeastern Retina Associates, PC., andagree to pay all reasonable collection costs and attorney fees in the event of default of payment on my charges. I further authorize and request insurance payments be made directlyto Southeastern Retina Associates, PC should they elect to receive such payment. My signature below indicates that I have read and fully understand the forth written authorization.Signature:Date:MEDIGAP (SIGNATURE ON FILE STATEMENT FOR MEDICARE TO CROSSOVER TO 2ND INSURANCE)Name of Beneficiary HICN Medigap Policy NumberI request that the payment of authorized Medigap benefits be made either to me or on my behalf to Southeastern Retina Associates, PC for any services furnished me bythe pro-vider. I authorize any holder of medical information about me to release to any information needed to determine these benefits orthe benefits payable for related services.Beneficiary Signature: Date:I understand that Southeastern Retina Associates, P.C.'s Notice of Privacy Practices is available to me at www.southeasternretina.com, and further understand I canrequest a paper copy today. I understand this document advises me of how certain health information about me may be used and disclosed by the practice.Signature:Date:

Identifying Information and Privacy OptionsSoutheastern Retina Associates (SERA) is now required to collect the followinginformation from all of our patients. Please check the appropriate boxes below:Preferred Language:EnglishOther:Ethnicity:HispanicNot Hispanic/LatinoUnknownRace:American Indian/Alaskan NativeAsianBlack/African AmericanNative Hawaiian/other Pacific IslanderWhiteOtherPrivacy Options:In some cases, it is not possible to reach our patients during work hours to discuss testresults, future appointments and account balances. Your response to the questionsbelow will give us guidance when we cannot contact you personally.YESNOSERA may leave messages on my answering machine/voice mail, orspeak with the person answering my home phone, regarding appointments.I would prefer to receive appointment reminders via: (select one or more)Text Message (enter cell #):Email:Phone/voice mail:YESNOSERA may speak with other people (listed below) regarding myinsurance, billing questions, or financial arrangements.YESNOSERA may speak with other people (listed below) regarding my medicalcare, lab or test results, or other medical information.Account and Billing Information:I would prefer to receive account / billing information via: (select one or more)Text Message (enter cell #):Email:Paper

SOUTHEASTERN RETINA ASSOCIATES, P.C.MEDICAL AND OCULARDiseases and Surgery of the Retina and VitreousSERA MDAccount #Patient Name: Sex: Age: Date:Eye Doctor (Not Retina): City or Address:Medical Doctor: City or Address:Please answer the following questions to the best of your ability.Give dates, a brief description, and which eye was involved to any yes question.Present IllnessPlease describe your current eye problem:Ocular HistoryCataractsHave you ever had any of the following: Right Eye Left Eye NoCataract Surgery Yes Left Surgeon and Date:Macular Degeneration Yes NoEye Injury NoIf yes, please explain YesGlaucoma Right NoAny history of lazy eye, patching, or muscle surgery as a child? YesMedical HistoryRetinal Detachment No Yes NoOther Eye Problems:Have you ever had any of the following .Seasonal Allergies Yes NoFood Allergies Yes NoHigh Blood Pressure Yes NoControlled with medicationHeart Problems Yes No Heart AttackPlease List: Yes Angina No Rhythm Problems Congestive Failure Migraine Tremors OtherNeurologyEndocrinePulmonary Yes Yes Yes No No No Stroke Seizures Parkinson’s Neuropathy Bells Palsy DiabetesHow Long? Type 1 Type 2 Thyroid SarcoidosisLast A1C Hemoglobin Asthma Emphysema Lung Disease COPD Phlebitis Tuberculosis Shortness of Breath Pneumonia Kidney Disease Kidney Stones UTI Mini Stroke (TIA)Last Blood Sugar BronchitisGenitourinary Yes No ProstateGastroenterology Yes No GERD –reflux IBS Ulcers Acid Reflux Diverticulitis Crohn’s Disease Anemia Lupus Hepatitis HIV Sickle Cell Disease Cancer Skin Breast Prostate Lung OtherHematology Yes NoRheumatology Yes No Arthritis Sjogren’s SyndromePsychiatry Yes No Depression AnxietySurgical History Gallbladder - Cholecystectomy Heart Stent Appendectomy Hernia - Herrniorhaphy Dementia Hiatal Hernia High Cholesterol Lyme Disease Rheumatoid Arthritis Alzheimer's Other Hysterectomy Bypass - CABG Tonsilectomy Prostatectomy Other