100 Debra Street  Seneca, SC 29678
Patient
Initials
Orlando A. Ricalde, M.D.
Board Certified Neurologist
(864) 885-9866  (864) 888-8307
Patient Responsibility Agreement
Lake Ridge Neurological requires that every patient must establish and
maintain routine medical treatment with a primary care physician. We will
not be responsible for or treat non-neurological conditions or complaints.
Without a primary care physician, we will be unable to continue offering
neurological care in our office.
We expect patients to be responsible for their care and to be prepared for
their visits with us. Be sure to have the following available at each visit:
 Insurance Card with Picture ID
 Form of Payment: Cash, Check, or Credit Card
 List of Medications & Refills Needed
 Prescription Formulary
 List of Questions you need to be addressed by the Physician
Patients will be made financially responsible for the following services at
Lake Ridge Neurological. These services are NOT covered by any insurance
company.
 Appointment No-Show Fee - $50
 Prescription Refill Charge - $10
 Prescription Prior Authorization - $10
 Phone Messages Requiring Physician & Clinical Staff Review - $15
 Patient Requesting Physician Telephone Conference - $25
 Special Forms & Letters Completed by Physician - from $10 to $100
Lake Ridge Neurological reserves the right to refuse care to patients and/or
family members exhibiting rude or inappropriate behavior in this office
and/or on the telephone.
************************************************************************************************************
I have read the above and understand my financial responsibility to Lake Ridge Neurological.
I have signed this agreement as acknowledgment of this understanding.
_________________________________________________
Patient or Legal Guardian, (if patient is under age 18)
____________________
Date