What to Bring to Your Appointment | Insurance and Payment Information
Patient Forms | Continence Center Patient Forms
Hospital Affiliations

What to Bring to Your Appointment

• Your insurance card
• Physician referral forms if required by insurance
• A list of current prescriptions and over-the-counter medications you are taking. We need a complete, detailed list of your current medications - to include the name, strength, how many times a day it is taken and when. For example:
  Buspar 15mg, 1 tablet 2 times a day
  Glucotrol 10mg, 1 tablet every morning
• All medical records, laboratory reports and/or X-ray reports and films pertaining to your urologic problem prior to your visit; you may be required by your referring physician to sign a release of medical information.
• You will also need to give a urine sample in our office. (Please do not bring one with you.)

Insurance and Payment Information

South Bend Clinic at Granger is a provider for Medicare and most major insurance plans. We provide insurance billing. Anything not covered by insurance will be your responsibility.

We request payment at the time of your appointment for services that are not covered by insurance. Your insurance company may also require you to pay a co-payment at the time of your appointment. When necessary, our staff will work closely with patients who require a payment plan.

If you have any questions regarding which insurance plans we accept or any patient billing concerns, please call us at the phone numbers below. Questions regarding your coverage and benefits should be directed to your employer or insurance company.

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Patient Forms

You can view and/or print the necessary patient forms for your appointment by following these easy instructions. In order to view and/or print the forms, you must have the Adobe Acrobat Reader®, which you probably already have on your computer. If not, you can easily and quickly download a free version of Adobe Acrobat Reader by going to their website Download Reader.

When viewing the forms in Adobe Acrobat Reader, the text might appear somewhat fuzzy; this is normal (the forms will print out clearly). To print, just click on the printer icon in the Adobe Reader toolbar above the document.

Once you have the Adobe Acrobat Reader installed, click on these links to view and print the following forms:

• Patient forms to be completed by male patients
  
  
• Patient forms to be completed by female patients
  
  
• Patient forms to be completed by Continence Center patients

Patient forms to be completed by male patients

• view/print Patient information sheet (PDF)
• view/print Patient health history sheet (PDF)
• view/print Urinary incontinence questionnaire (PDF)
• view/print Prostate health symptom score (BPH) (PDF)
• view/print Sexual health questionnaire (PDF)

Patient forms to be completed by female patients

• view/print Patient information sheet (PDF)
• view/print Patient health history sheet (PDF)
• view/print Urinary incontinence questionnaire (PDF)

Patient forms to be completed by Continence Center patients

Thank you for choosing the Continence Center for your healthcare. You can contact the office to schedule an appointment by calling 574.243.4499. Please complete these forms and bring them with you to your appointment:

• view/print Continence Center Forms (PDF)
• view/print Urogenital Distress Inventory (PDF)

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Hospital Affiliations

Drs. Walker and Gonzalez maintain privileges at the following hospitals:

• St. Joseph Regional Medical Center
• Memorial Hospital
• St. Joseph Community Hospital
• Bremen Community Hospital

Dr. Carl Walker
Dr. Fernando Gonzalez
South Bend Clinic at Granger
14950 State Road 23
(corner of SR 23 and Fir Road)
Granger, IN 46530
Tel: 574.243.4450
Fax: 574.243.4405

click here for a map

Continence Center: 574.243.4499