2023-03-07T07:54:48-06:00 2022-06-30 390758449 WIPFLI LLP PO BOX 8010 WAUSAU WI 54402 990 2021-07-01 010284446 REDINGTON-FAIRVIEW GENERAL HOSPITAL REDI 2074745121 PO BOX 468 SKOWHEGAN ME 049760468 ELMER DOUCETTE CFO 2074745121 2023-03-06 1 ELMER DOUCETTE 999009999 JOSHUA J BOYLE CPA P01811665 7158453111 2023-03-06 3 AAL1 IAL1 2021 2023-04-26 12:10:37Z RICHARD D WILLETT PO BOX 468 SKOWHEGAN ME 049760468 142169150 0 X WWW.RFGH.NET X 1969 ME SEE SCHEDULE OREDINGTON-FAIRVIEW GENERAL HOSPITAL'S MISSION IS TO DEVELOP, PROVIDE, AND FACILITATE QUALITY, SAFE, COMPREHENSIVE, COST-EFFECTIVE HEALTH SERVICES FOR THE PEOPLE WE SERVE. WE AFFIRM A COMMITMENT TO MAINTAIN OUR UNIQUE COMMUNITY HOSPITAL IDENTITY, OFFERING PERSONALIZED SERVICES. 9 6 905 36 0 0 1991348 2481086 113280331 133598589 923804 2228777 5133331 3860698 121328814 142169150 0 0 0 0 67270224 77990660 0 0 0 48512706 58750939 115782930 136741599 5545884 5427551 167276910 132225401 50955706 39020050 116321204 93205351 X REDINGTON-FAIRVIEW GENERAL HOSPITAL'S MISSION IS TO DEVELOP, PROVIDE, AND FACILITATE QUALITY, SAFE, COMPREHENSIVE, COST-EFFECTIVE HEALTH SERVICES FOR THE PEOPLE WE SERVE. WE AFFIRM A COMMITMENT TO MAINTAIN OUR UNIQUE COMMUNITY HOSPITAL IDENTITY, OFFERING PERSONALIZED SVCS. 0 0 66734511 103085680 RFGH PROVIDES 24 HOUR SEVEN DAY A WEEK EMERGENCY SERVICES. THESE SERVICES INCLUDE AN EMERGENCY DEPARTMENT STAFFED WITH PHYSICIANS 24 HOURS A DAY AS WELL AS AN AMBULANCE SERVICE WHICH OPERATES 24 HOURS A DAY. DURING FISCAL 2022, RFGH HAD 23,196 EMERGENCY DEPARTMENT VISITS AND 3,950 AMBULANCE RUNS. IN ADDITION TO EMERGENCY SERVICES, THE HOSPITAL PROVIDES A FULL RANGE OF SERVICES, RADIOLOGY, C.T., ULTRASOUND, NUCLEAR MEDICINE, BLOOD BANK, PATHOLOGY, CARDIOLOGY AND LABORATORY SERVICES. 30757325 14585935 RFGH OPERATES A NUMBER OF PHYSICIAN OFFICES IN ORDER TO BETTER SERVE THE RESIDENTS OF SOMERSET COUNTY. DURING FISCAL 2022, THESE PHYSICIAN SPECIALTIES INCLUDED INTERNAL MEDICINE, ENDOCRINOLOGY, GENERAL SURGERY, ORTHOPEDICS, PEDIATRICS, FAMILY MEDICINE, OBSTETRICS, GASTROENTEROLOGY, NEUROLOGY, UROLOGY, & CARDIOLOGY. DURING FISCAL 2022, THESE PHYSICIAN SPECIALTIES HAD 56,598 VISITS. 20580530 15112554 RFGH IS LICENSED AS A CRITICAL ACCESS HOSPITAL OPERATING 25 BEDS. RFGH EMPLOYS HOSPITALISTS WHO ARE PHYSICIANS DEDICATED TO THE TREATMENT OF INPATIENTS. INPATIENT SERVICES INCLUDE MEDICAL AND SURGICAL, SPECIAL CARE, OBSTETRICS AND PEDIATRICS. DURING FISCAL 2022, RFGH PROVIDED INPATIENT SERVICES TO 1,303 PATIENTS WHO STAYED 5,990 PATIENT DAYS. MEDICARE AND MEDICAID PATIENTS REPRESENTED 50% OF RFGH'S INPATIENTS. 1659413 1590610 REDINGTON-FAIRVIEW GENERAL HOSPITAL OPERATES SOMERSET PUBLIC HEALTH, A PROGRAM WHOSE PURPOSE IS TO PROTECT AND IMPROVE THE QUALITY OF LIFE AND HEALTH OF ALL GREATER SOMERSET COUNTY RESIDENTS. 1659413 1590610 119731779 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 0 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 32 0 1 905 1 0 0 0 0 0 0 0 0 0 0 0 0 X 9 6 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 0 0 X RICHARD D WILLETT 2078582315 46 FAIRVIEW AVE SKOWHEGAN ME 049760468 MICHAEL CURRAN MD DIRECTOR 50.00 X 525668 0 3461 GINA GOMEZ MD DIRECTOR 50.00 X 384528 0 5862 MICHAEL LAMBKE MD DIRECTOR 50.00 X 194393 0 2714 CHRISTOPHER PERKINS PRESIDENT 2.00 X X 0 0 0 L JOSEPH CLARK VICE PRESIDENT 2.00 X X 0 0 0 JEFFREY MCGOWN TREASURER 2.00 X X 0 0 0 VICKY ALWARD DIRECTOR 2.00 X 0 0 0 SAM HIGHT DIRECTOR 2.00 X 0 0 0 WILLIAM LANEY DIRECTOR 2.00 X 0 0 0 RICHARD D WILLETT CEO/SECRETARY 50.00 X 409829 0 10533 DANA C KEMPTON ASSOCIATE DIRECTOR 50.00 X 321347 0 8912 ELMER DOUCETTE CFO 50.00 X 258820 0 1695 TIRUNELLAI R SHANKAR MD SURGEON 50.00 X 555570 0 3731 JOHN COMIS MD ER PHYSICIAN 50.00 X 451871 0 5435 ANDREW BRAY MD ER PHYSICIAN 50.00 X 441065 0 0 AMIR BAIG MD ANESTHESIOLOGIST 50.00 X 416183 0 4036 JUAN FEBRES VALECILLOS MD SURGEON 50.00 X 415209 0 0 4374483 0 46379 84 0 1 0 FOCUSONE SOLUTIONS PO BOX 850861 MINNEAPOLIS MN 554850861 CLINICAL STAFFING 3149358 WEATHERBY LOCUM PO BOX 972633 DALLAS TX 75397 CLINICAL STAFFING 1391672 AFFILIATED LABORATORY INC PO BOX 638 BANGOR ME 04402 LAB TESTING 1166548 COMPHEALTH 7259 S BINGHAM JCT BLVD MIDVALE UT 84047 CLINICAL STAFFING 1026196 VISTA STAFFING SOLUTIONS 275 EAST 200 SOUTH SALT LAKE CITY UT 84111 CLINICAL STAFFING 883039 30 1180547 1300539 2481086 NET PATIENT REVENUE 622110 133598589 133598589 133598589 2228777 2228777 CONTRACT PHARMACY 456110 3046422 3046422 OTHER MISCELLANEOUS 622110 518461 518461 CAFETERIA 722514 295815 295815 3860698 142169150 137163472 0 2524592 2005820 1059690 946130 54562829 49962028 4600801 -164483 -131545 -32938 17795946 14232331 3563615 3790548 3031496 759052 2979 2979 426022 426022 10343 10343 243562 243562 13388353 10948179 2440174 69830 69830 6346975 5277228 1069747 3759837 3317947 441890 1256255 1048479 207776 58233 47532 10701 174701 142597 32104 768252 616113 152139 4387033 3518255 868778 669426 480797 188629 BAD DEBT EXPENSE 11214975 11214975 PHARMACEUTICALS 10490597 10490597 HOSPITAL PROVIDER TAX 2224504 2224504 MISC AND OTHER EXPENSES 2202531 1293249 909282 1056531 957327 99204 136741599 119731779 17009820 0 22970565 8902572 3122448 4133156 9669362 9259855 876542 934760 1762424 2630169 243552 247562 90705461 64375216 26062051 26330245 87658094 72192691 14911872 7594391 167276910 132225401 12668153 11659073 20964680 19321417 17322873 8039560 50955706 39020050 X 115083285 92057177 1237919 1148174 116321204 93205351 167276910 132225401 X 5427551 -16103183 -12440221 X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 10343 10343 136731311 136741654 1000000 250000 0 0 1000000 1000000 1000000 1000000 4000000 6000000 11288 9986 9954 10343 41571 250000 250000 250000 250000 1000000 1500000 396680 396680 52351756 38195471 14156285 33241535 26179745 7061790 4715490 4715490 26330245 PENSION ASSET 7113656 DEFERRED FINANCING CHARGES 372997 DISCOUNT ON BONDS PAYABLE 10038 SOMERSET FITNESS CENTER 97700 7594391 ESTIMATED THIRD PARTY SETTLEMENTS 626196 MEDICARE ADVANCE PAYMENT - CURRENT 7413364 8039560 114850992 -16103183 -16103183 130954175 11214975 11214975 142169150 125526624 0 125526624 11214975 11214975 136741599 PART XI, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 11,214,975. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 11,214,975. 1 1 1 X 1 X 1 1 0 0 324953 324953 0.00240 324953 324953 0.00240 1726551 1726551 0.01260 30757325 14585935 16171390 0.11830 32483876 14585935 17897941 0.13090 32808829 14585935 18222894 0.13330 1 5331233 29439100 31366732 -1927632 X 1 1 1 1 REDINGTON-FAIRVIEW GENERAL HOSPITAL 46 FAIRVIEW AVENUE PO BOX 468 SKOWHEGAN ME 04976 WWW.RFGH.NET 38095 X REDINGTON-FAIRVIEW GENERAL HOSPITAL 1 0 0 1 X X X X X X 22 1 1 1 1 X WWW.RFGH.NET X 1 22 0 1 0 1 X 150.000000000000 225.000000000000 1 1 X X X 1 X WWW.RFGH.NET X X X X X 0 0 X X X X 1 0 0 REDINGTON-FAIRVIEW GENERAL HOSPITAL PART V, SECTION B, LINE 5: HOW THE HOSPITAL TOOK INTO ACCOUNT INPUT FROM PERSONS WHO REPRESENT THE COMMUNITY AND IDENTIFY THE PERSONS THE HOSPITAL FACILITY CONSULTED:COMMUNITY OUTREACH AND ENGAGEMENT FOR THE MAINE SHARED CHNA INCLUDED 17 COUNTY FORUMS, 9 COMMUNITY SPONSORED EVENTS, AND 1,000 ORAL SURVEYS. ONE VIRTUAL COMMUNITY FORUM WAS HELD IN SOMERSET COUNTY WITH 42 ATTENDEES. PERSONS FROM THE FOLLOWING ORGANIZATIONS REPRESENTING BROAD INTERESTS OF THE COMMUNITY WHO WERE CONSULTED DURING THE ENGAGEMENT PROCESS: COBURN PARK COMMISSION, HEALTHY LIVING FOR ME, KENNEBEC BEHAVIORAL HEALTH, MAINE CENTER FOR DISEASE CONTROL & PREVENTION, MAINEGENERAL HEALTH, MAINE GENERAL MEDICAL CTR, NORTHERN LIGHT HEALTH, NORTHERN LIGHT HOMECARE & HOSPICE, NORTHERN LIGHT INLAND HOSPITAL, NORTHERN LIGHT SEBASTICOOK VALLEY HOSPITAL, OFFICE OF CHILD & FAMILY SERVICES, REDINGTON-FAIRVIEW GENERAL HOSPITAL, RSU #74 SCHOOL DISTRICT, SKOWHEGAN REGIONAL CHAMBER OF COMMERCE, SOMERSET PUBLIC HEALTH, AND TRUSTED RIDE CERTIFIED. REDINGTON-FAIRVIEW GENERAL HOSPITAL PART V, SECTION B, LINE 6A: OTHER HOSPITALS AND OTHER ORGANIZATIONS INCLUDED IN CONDUCTING COMMUNITY HEALTH NEEDS ASSESSMENT:RFGH HAS COLLABORATED WITH THE MAINE SHARED COMMUNITY HEALTH NEEDS ASSESSMENT (MAINE SHARED CHNA) - A COLLABORATIVE BETWEEN CENTRAL MAINE HEALTHCARE, MAINE CENTER FOR DISEASE CONTROL & PREVENTION, MAINEGENERAL HEALTH, MAINEHEALTH, AND NORTHERN LIGHT HEALTH. THE VISION OF THE MAINE SHARED CHNA IS TO TURN HEALTH DATA INTO ACTION SO THAT MAINE WILL BECOME THE HEALTHIEST STATE IN THE U.S. THE MISSION OF THE MAINE SHARED CHNA IS TO: CREATE SHARED CHNA REPORTS, ENGAGE AND ACTIVATE COMMUNITIES, AND SUPPORT DATA-DRIVEN HEALTH IMPROVEMENTS FOR MAINE PEOPLE. REDINGTON-FAIRVIEW GENERAL HOSPITAL PART V, SECTION B, LINE 11: HOW THE HOSPITAL FACILITY IS ADDRESSING THE SIGNIFICANT NEEDS......:ATTACHED IS THE 2020 - 2021 RFGH COMMUNITY HEALTH WORK-PLAN. PART V, SECTION B, LINE 22D: HOW THE HOSPITAL DETERMINED THE MAXIMUM AMOUNTS THAT CAN BE CHARGED FAP-ELIGIBLE INDIVIDUALS:ALL ACCOUNT GUARANTORS WHO EXPRESS AN INABILITY TO PAY FOR SERVICES ARE SCREENED FOR ELIGIBILITY FOR FINANCIAL ASSISTANCE USING AN APPLICATION AND GUIDELINES ESTABLISHED BY THE HOSPITAL. UNDER THESE GUIDELINES, ELIGIBLE APPLICANTS MAY QUALIFY FOR 100% CHARITY CARE OR DISCOUNTED CHARGES RANGING FROM 25% TO 100%. PART I, LINE 7: PART I, LINE 7A: METHODOLOGY USED TO ESTIMATE FINANCIAL ASSISTANCE AT COST:CHARITY CARE WRITE-OFFS ARE RECORDED AT GROSS CHARGES. IN ORDER TO COMPUTE THE COST OF THESE SERVICES, THE HOSPITAL ADJUSTED BOTH GROSS CHARGES AND EXPENSES BY EXCLUDING THE GROSS CHARGES AND EXPENSES ASSOCIATED WITH SUBSIDIZED HEALTH SERVICES REPORTED IN SCHEDULE H PART I LINE 7G AND CALCULATED A RATIO OF COST-TO-CHARGES. THE RESULTING RATIO OF 47.54% WAS APPLIED TO THE GROSS CHARGES PERTAINING TO CHARITY CARE WRITE-OFFS.PART I, LINE 7E:METHODOLOGY USED TO ESTIMATE COMMUNITY HEALTH IMPROVEMENT SERVICES AND COMMUNITY BENEFIT OPERATIONS:THESE COMMUNITY BENEFIT EXPENSES REPRESENT THE ACTUAL EXPENDITURES OF OPERATING THE SOMERSET PUBLIC HEALTH COLLABORATIVE WHICH SERVES MOST OF MAINE'S SOMERSET COUNTY. PART I, LINE 7G: METHODOLOGY USED TO ESTIMATE SUBSIDIZED HEALTH SERVICES:THESE COMMUNITY BENEFIT EXPENSES REPRESENT THE DIRECT AND INDIRECT COSTS OF OPERATING PHYSICIAN PRACTICES WHICH OPERATE WITH REVENUES THAT ARE INSUFFICIENT TO COVER THE OVERALL COSTS. INDIRECT COSTS ARE CALCULATED USING AN ALLOCATION METHOD SIMILAR TO MEDICARE COST REPORT METHODS OF ALLOCATING OVERHEAD COSTS. PART III, LINE 2: BAD DEBT WRITE-OFFS ARE RECORDED AT GROSS CHARGES. IN ORDER TO COMPUTE THE COST OF THESE SERVICES, THE HOSPITAL ADJUSTED BOTH GROSS CHARGES AND EXPENSES BY EXCLUDING THE GROSS CHARGES AND EXPENSES ASSOCIATED WITH SUBSIDIZED HEALTH SERVICES REPORTED IN SCHEDULE H PART I LINE 7G AND CALCULATED A RATIO OF COST-TO-CHARGES. THE RESULTING RATIO OF 47.54% WAS APPLIED TO THE GROSS CHARGES PERTAINING TO BAD DEBT WRITE-OFFS. PART III, LINE 4: FOOTNOTE DESCRIBING IMPLICIT PRICE CONCESSIONS, FORMERLY REFERRED TO AS BAD DEBTS, CAN BE FOUND IN THE 1ST PARAGRAPH ON PAGE 14 OF THE ATTACHED AUDITED FINANCIAL STATEMENTS. PART III, LINE 8: MEDICARE SHORTFALL METHOD OF CALCULATING:MEDICARE COSTS WERE OBTAINED FROM THE FILED MEDICARE COST REPORT. THE COSTS ARE BASED ON MEDICARE ALLOWABLE COSTS AS REPORTED ON WORKSHEET B. INPATIENT MEDICARE COSTS ARE CALCULATED BASED UPON A COMBINATION OF ALLOWABLE COST PER DAY MULTIPLIED BY MEDICARE DAYS FOR ROUTINE SERVICES PLUS A COST-TO-CHARGE RATIO MULTIPLIED BY MEDICARE CHARGES BY ANCILLARY DEPARTMENT. OUTPATIENT COST IS CALCULATED BASED ON A COST-TO-CHARGE RATIO MULTIPLIED BY MEDICARE CHARGES BY ANCILLARY DEPARTMENT. PART III, LINE 9B: COLLECTION PRACTICES:THE HOSPITAL'S COLLECTION POLICY CONTAINS THE GUIDELINES FOR FINANCIAL ASSISTANCE, AND CONTAINS PROVISIONS FOR HOSPITAL STAFF TO EXTEND TO QUALIFIED PATIENTS WHO WOULD LIKELY MEET SLIDING SCALE FEE CRITERIA THE OPPORTUNITY TO APPLY FOR DISCOUNTED CARE. HOSPITAL RESOURCES ARE MADE AVAILABLE TO PATIENTS REQUIRING ASSISTANCE IN COMPLETING APPLICATIONS. PATIENTS WHO QUALIFY FOR FINANCIAL ASSISTANCE UNDER THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY ARE PROVIDED DISCOUNTS RANGING FROM 25% TO 100% OF CHARGES. ONCE QUALIFIED PATIENTS MAY BE EXTENDED REDUCED FEE FOR HEALTH CARE SERVICES RECEIVED IN THE FUTURE. ALL PATIENTS ARE ASKED TO REAPPLY ANNUALLY TO THE SLIDING FEE PROGRAM. OUTSIDE COLLECTION AGENCIES CONTRACTED WITH THE HOSPITAL MUST SPECIFY THEIR STANDARDS AND SCOPE OF PRACTICES, ALL OF WHICH MUST BE IN COMPLIANCE WITH THE COLLECTION POLICY. PART VI, LINE 2: NEEDS ASSESSMENT: DESCRIBE HOW THE ORGANIZATION ASSESSES THE HEALTH CARE NEEDS OF THE COMMUNITIES IT SERVES, IN ADDITION TO ANY CHNAS REPORTED:REDINGTON-FAIRVIEW GENERAL HOSPITAL OPERATES SOMERSET PUBLIC HEALTH (SPH), A PROGRAM WHOSE PURPOSE IS TO PROTECT AND IMPROVE THE QUALITY OF LIFE AND HEALTH OF ALL GREATER SOMERSET COUNTY RESIDENTS. SPH PROVIDES PLANNING AND EVALUATION OF BOTH LONG AND SHORT RANGE STRATEGIES FOR ESSENTIAL PUBLIC HEALTH SERVICES. SPH INVOLVES CITIZENS IN DEVELOPING AND CARRYING OUT CHRONIC DISEASE PREVENTION THROUGH VARIOUS INITIATIVES. SPH MOBILIZES BOTH PUBLIC AND PRIVATE RESOURCES IN SUPPORT OF THESE INITIATIVES AND COORDINATES EFFORTS THROUGHOUT THE COMMUNITY. BY WORKING WITH CITIZENS, SPH SERVES AS ADVOCATES ON MATTERS OF POLICIES THAT AFFECT HEALTH STATUS, WHILE PROMOTING INSTITUTIONAL IMPROVEMENT AND DESIRABLE CHANGES IN SOCIAL POLICY AND ENVIRONMENTAL CHANGE. SPH IMPLEMENTS PROGRAMS FINANCED THROUGH GRANTS, OR DELEGATES IMPLEMENTATION TO OTHER AGENCIES. SPH ALSO IDENTIFIES AND PURSUES OTHER AVAILABLE FUNDS DEEMED IMPORTANT FOR THE HEALTH OF CITIZENS. IN ITS WORK TO IMPROVE AND PROTECT PUBLIC HEALTH AND REDUCE CHRONIC DISEASE, SPH FOCUSES ITS EFFORTS AND FUNDING ON SUBSTANCE ABUSE AND TOBACCO PREVENTION, PHYSICAL ACTIVITY AND NUTRITION PROMOTION, AND WORKSITE WELLNESS. PART VI, LINE 3: PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE:REDINGTON-FAIRVIEW GENERAL HOSPITAL PROVIDES THE FOLLOWING INFORMATION IN THE FIRST BILL THAT EACH PATIENT RECEIVES:FINANCIAL ASSISTANCE PROGRAM (AND PLAIN LANGUAGE SUMMARY)REDINGTON-FAIRVIEW GENERAL HOSPITAL (RFGH) FOLLOWS MAINE STATE LAW AND PROVIDES FREE HOSPITAL SERVICE TO THOSE INDIVIDUALS WHO CANNOT AFFORD TO PAY UNDER "CATEGORY A FREE CARE". RFGH HAS AN ADDITIONAL PROGRAM "CATEGORY B" AVAILABLE WHICH MAY PROVIDE HOSPITAL SERVICES AT A REDUCED AMOUNT TO THOSE INDIVIDUALS WHO CANNOT AFFORD TO PAY. IF YOU BELIEVE YOU QUALIFY FOR ASSISTANCE, YOU MAY COMPLETE AN APPLICATION AT THE PATIENT ACCOUNTS OFFICE, LOCATED AT 22 JONES STREET, SKOWHEGAN, ME 04976 (THE WHITE BUILDING IN THE BACK PARKING LOT OF THE HOSPITAL) OR YOU MAY COMPLETE THE APPLICATION AND MAIL IT TO REDINGTON-FAIRVIEW GENERAL HOSPITAL, P.O. BOX 468, SKOWHEGAN, ME 04976. PLEASE NOTE YOUR APPLICATION MAY BE DELAYED IF COMPLETE INFORMATION IS NOT PROVIDED.FOR A FREE COPY OF THIS FINANCIAL ASSISTANCE POLICY AND FINANCIAL ASSISTANCE APPLICATION YOU MAY ACCESS THEM AT OUR WEBSITE AT WWW.RFGH.NET UNDER "PATIENT INFORMATION" THEN "BILLING & INSURANCE", OR YOU MAY CALL OUR PATIENT ACCOUNTS DEPARTMENT AT (207) 858-8367. OUR PATIENT ACCOUNTS REPRESENTATIVES ARE ALSO AVAILABLE TO ASSIST YOU IN COMPLETING YOUR APPLICATION. OUR OFFICES ARE OPEN MONDAY TO FRIDAY FROM 7:00AM TO 4:30PM.TO COMPLETE THE APPLICATION PROCESS, YOU (OR YOUR DESIGNEE) WILL NEED TO PRESENT AND PROVIDE PROOF OF THE FOLLOWING TO DETERMINE YOUR ELIGIBILITY FOR ASSISTANCE: YOUR MOST RECENT FEDERAL INCOME TAX RETURN. IF YOU DO NOT FILE TAXES, YOU WILL HAVE TO SIGN A DOCUMENT STATING YOU DO NOT FILE INCOME TAXES. YOUR LAST THREE MONTHS' WAGE STUBS OR A COPY OF YOUR WAGE STUB WITH YEAR TO DATE FOR A PERIOD OF AT LEAST THREE MONTHS. COPY OF LAST THREE MONTHS CHECKING AND SAVINGS ACCOUNT STATEMENTS. IF APPLYING UNDER CATEGORY B AND SELF-EMPLOYED, THREE (3) MONTHS OF BUSINESS CHECKING STATEMENTS WILL ALSO BE REQUIRED. LIST OF ALL INCOME INCLUDING ALIMONY, CHILD SUPPORT, STOCKS, BONDS, ANNUITIES, AND RENTAL INCOME. PROOF OF INSURANCE OF ANY KIND, INCLUDING HEALTH SAVINGS ACCOUNTS/CO-OP PROGRAMS TO HELP PAY FOR YOUR CARE. YOU WILL NEED TO SHOW THAT YOUR HSA HAS BEEN FULLY UTILIZED PRIOR TO APPROVAL. YOU WILL ALSO BE REQUIRED TO APPLY TO THE STATE OF MAINE FOR MAINECARE COVERAGE. IF YOU ARE NOT ELIGIBLE YOU WILL BE ISSUED A DENIAL LETTER BY THE STATE AND MUST PROVIDE A COPY OF THE ENTIRE PACKET, INCLUDING A LIST OF ASSETS AS PART OF YOUR RFGH FINANCIAL ASSISTANCE APPLICATION. {NOTE: THIS DENIAL LETTER IS ONLY GOOD FOR SIX MONTHS.} IF YOU DO NOT QUALIFY FOR MAINECARE, YOU ARE ALLOWED TO ASK FOR A FAIR HEARING. THE STATE DEPARTMENT OF HUMAN SERVICES WILL TELL YOU HOW TO APPLY FOR A FAIR HEARING. TO BE ELIGIBLE FOR FREE CARE (CATEGORY A) OR DISCOUNTED RATES (CATEGORY B), YOUR FAMILY INCOME MUST BE BELOW THE LEVELS LISTED IN THE TABLES BELOW. THE HOSPITAL WILL CONSIDER THE HIGHEST INCOME LEVEL AVAILABLE BASED ON THE NUMBER OF DEPENDENTS CLAIMED ON YOUR TAXES. IN ADDITION, RFGH WILL PROVIDE YOU WITH A FINAL DETERMINATION OF YOUR ELIGIBILITY FOR ASSISTANCE WITHIN FIVE (5) WORKING DAYS OF YOUR COMPLETED APPLICATION. IF YOU DO NOT QUALIFY FOR A FULL 100% RFGH DISCOUNT UNDER (CATEGORY A) OR (CATEGORY B), A MONTHLY PAYMENT PLAN WILL BE CALCULATED BY THE PATIENT ACCOUNTS REPRESENTATIVE. ANY ELIGIBLE INDIVIDUAL WILL NOT BE CHARGED MORE FOR THEIR MEDICALLY NECESSARY OR EMERGENCY CARE THAN THE AMOUNT GENERALLY BILLED TO INDIVIDUALS WHO HAVE INSURANCE COVERING SUCH CARE. IN THE EVENT OF NON-PAYMENT OF ANY AMOUNT DETERMINED TO BE THE RESPONSIBILITY OF THE PATIENT/GUARANTOR, AND IN THE ABSENCE OF AN APPLICATION FOR ASSISTANCE, THE HOSPITAL MAY REFER THE ACCOUNT(S) TO AN OUTSIDE COLLECTION AGENCY. SUCH ACTION MAY RESULT IN AN ADVERSE ENTRY ON THE PATIENT'S/GUARANTOR'S CREDIT RATING OR THE INITIATION OF LEGAL PROCEEDINGS.YOU WILL NEED TO SIGN A PAYMENT AGREEMENT CONTRACT AND FAITHFULLY COMPLETE YOUR PAYMENT PORTION IN ORDER TO RECEIVE THE NEGOTIATED DISCOUNT.ALL MEDICALLY NECESSARY SERVICES PROVIDED BY RFGH AND ITS EMPLOYED PROVIDERS ARE ELIGIBLE FOR CATEGORY A FREE CARE OR CATEGORY B DISCOUNTS. SERVICES NOT PRIOR AUTHORIZED DUE TO FAILURE TO SUPPLY INSURANCE INFORMATION ARE NOT ELIGIBLE FOR FREE OR DISCOUNTED CARE. SERVICES THAT ARE NOT MEDICALLY NECESSARY ARE NOT COVERED UNDER THIS PROGRAM AND REQUIRE PRE-PAYMENT BEFORE SERVICES ARE RENDERED.CATEGORY AFREE CARE @ 100%FAMILY SIZE ANNUAL INCOME1_______20,3852_______27,4653_______34,5454_______41,6255_______48,7056_______55,7857_______62,8658_______69,945FOR EACH ADDITIONAL PERSON, ADD $7,080 ANNUALLY.CATEGORY B RFGH FINANCIAL ASSISTANCE PROGRAMDISCOUNT 100% 75% 50% 25% INCOME INCOME INCOME INCOME FAMILY SIZE TO TO TO TO1____________32,616____37,336____42,056____46,776 2____________39,224____43,944____48,664____53,384 3____________45,832____50,552____55,272____59,9924____________52,440____57,160____61,880____66,600 5____________59,048____63,768____68,488____73,208 6____________65,656____70,376____75,096____79,816 7____________72,264____76,984____81,704____86,424 8____________78,872____83,592____88,312____93,032 FOR EACH ADDITIONAL PERSON, ADD $6,608 ANNUALLY.IF YOU PROVIDE FALSE OR INACCURATE INFORMATION IN YOUR APPLICATION ANY AND ALL FINANCIAL ASSISTANCE PROVIDED WILL BE REVOKED AND BALANCES WILL BE THE PATIENT RESPONSIBILITY. PART VI, LINE 4: COMMUNITY INFORMATION:REDINGTON-FAIRVIEW GENERAL HOSPITAL IS AN INDEPENDENT 25-BED CRITICAL ACCESS HOSPITAL LOCATED IN SKOWHEGAN, MAINE. THE HOSPITAL PROVIDES HEALTH CARE TO MORE THAN 51,000 RESIDENTS LIVING IN SOMERSET COUNTY, MAINE. ITS PRIMARY SERVICE AREA EXTENDS FROM SKOWHEGAN TO THE CANADIAN BORDER. A STATE OF THE ART MEDICAL OFFICE BUILDING ADJACENT TO THE HOSPITAL PROVIDES EASY ACCESS TO PRIMARY AND SPECIALTY CARE. A MEDICAL STAFF OF MORE THAN 40 PHYSICIANS SKILLED IN A VARIETY OF FIELDS, AND APPROXIMATELY 750 FULL AND PART-TIME PROFESSIONAL AND TECHNICAL EMPLOYEES ENSURE THE DELIVERY OF PROGRESSIVE HEALTH AND MEDICAL SERVICES.SOMERSET COUNTY FACTS:- HAS 23 TOWNS, SOME LARGE AND SOME AS SMALL AS 110 PEOPLE. - TOTAL POPULATION IS APPROXIMATELY 51,000, AND 4 OF 5 INDIVIDUALS LIVE IN A RURAL AREA.- IN NOVEMBER 2021 THE UNEMPLOYMENT RATE WAS 5.4% WHICH WAS THE HIGHEST UNEMPLOYMENT RATE IN THE STATE(4.1% STATE AVG).- HIGH POVERTY RATES ARE PRESENT IN ALL AGE GROUPS.- IN 2021, THE PERCENT OF PERSONS IN POVERTY WAS 14.8% COMPARED TO 11.5% FOR THE STATE.- FOR THE YEARS 2013-2017, 37% OF CHILDREN LIVED IN SINGLE PARENT FAMILIES.- IN 2021, THE MEDIAN HOUSEHOLD INCOME OF $47,488 IS $15,694 (25%) LESS THAN THE REST OF THE STATE AT $63,182. PART VI, LINE 5: PROMOTION OF COMMUNITY HEALTH:THE HOSPITAL IS LOCATED IN A MEDICALLY UNDERSERVED AREA. CONSEQUENTLY, THE HOSPITAL MAINTAINS AN OPEN MEDICAL STAFF. THE BOARD OF DIRECTORS CONSISTS OF 6 INDEPENDENT COMMUNITY MEMBERS AND 3 MEDICAL STAFF MEMBERS. IN ADDITION TO THE PROGRAMS OUTLINED IN OTHER AREAS OF THE FORM 990, THE HOSPITAL OPERATES A FITNESS FACILITY WHICH OPERATES AT A LOSS. THE FITNESS FACILITY OPERATES MANY PROGRAMS WHICH PROMOTES WELLNESS. OTHER WELLNESS PROGRAMS ARE ALSO PROVIDED THROUGH THE INDOOR POOL THAT THE HOSPITAL OPERATES AT A LOSS. THE POOL PROMOTES WELLNESS AMONG INDIVIDUALS WHO WOULD NOT BE ABLE TO OTHERWISE EXERCISE (DISABLED INDIVIDUALS WITH CHRONIC PAIN, MS AND OTHER DEBILITATING DISEASES). THE HOSPITAL ALSO OPERATES SOMERSET PUBLIC HEALTH, A PROGRAM WHOSE PURPOSE IS TO PROTECT AND IMPROVE THE QUALITY OF LIFE AND HEALTH OF ALL GREATER SOMERSET COUNTY RESIDENTS. X X X X 0 0 0 1 0 0 0 0 0 TIRUNELLAI R SHANKAR MD SURGEON 346815 0 194091 0 14664 0 3731 0 0 0 559301 0 0 0 MICHAEL CURRAN MD DIRECTOR 410941 0 100064 0 14663 0 3461 0 0 0 529129 0 0 0 JOHN COMIS MD ER PHYSICIAN 436043 0 0 0 15828 0 5435 0 0 0 457306 0 0 0 ANDREW BRAY MD ER PHYSICIAN 425237 0 0 0 15828 0 0 0 0 0 441065 0 0 0 RICHARD D WILLETT CEO/SECRETARY 395187 0 0 0 14642 0 10533 0 0 0 420362 0 0 0 AMIR BAIG MD ANESTHESIOLOGIST 400355 0 0 0 15828 0 4036 0 0 0 420219 0 0 0 JUAN FEBRES VALECILLOS MD SURGEON 400545 0 0 0 14664 0 0 0 0 0 415209 0 0 0 GINA GOMEZ MD DIRECTOR 368704 0 0 0 15824 0 5862 0 0 0 390390 0 0 0 DANA C KEMPTON ASSOCIATE DIRECTOR 306701 0 0 0 14646 0 8912 0 0 0 330259 0 0 0 ELMER DOUCETTE CFO 244242 0 0 0 14578 0 1695 0 0 0 260515 0 0 0 MICHAEL LAMBKE MD DIRECTOR 174530 0 5451 0 14412 0 2714 0 0 0 197107 0 0 0 PART I, LINE 5 PHYSICIANS EMPLOYED BY THE HOSPITAL PARTICIPATE IN AN INCENTIVE BASED COMPENSATION PROGRAM. THE PROGRAM IS BASED UPON A REVENUE TARGET WHICH WILL PRODUCE A TARGET COMPENSATION LEVEL, WHICH IS BASED ON BOTH LOCAL AND NATIONAL BENCHMARK INFORMATION. IN ORDER TO ALIGN THE PHYSICIAN WITH THE CHARITABLE MISSION OF THE HOSPITAL, THE PROGRAM IS BASED ON THE HOSPITAL'S ACTUAL CHARGES, SO THAT THE PHYSICIAN WILL HAVE AN INCENTIVE TO TAKE ALL PATIENTS REGARDLESS OF THEIR ABILITY TO PAY. THE SUM OF ALL CHARGES FOR SERVICES PERFORMED BY THE PHYSICIAN IS TABULATED ON A QUARTERLY BASIS. THAT TABULATION IS THEN DIVIDED BY THE REVENUE TARGET, WHICH IS MULTIPLIED TIMES THE TARGET COMPENSATION LEVEL. IF A PHYSICIAN'S ACTUAL COMPENSATION IS LESS THAN THE CALCULATED SALARY, THE PHYSICIAN WILL RECIEVE A BONUS PAYMENT THAT RECOGNIZES THE PHYSICIAN'S CONTIRBUTION TO THE HOSPITAL'S ACHIEVEMENT OF IT'S CHARITABLE MISSION TO PROVIDE HEALTH SERVICES FOR THE BENEFIT OF THE COMMUNITY. A MAINE HEALTH & HIGHER EDUCATION FACILITY AUTHORITY 010314384 560427JA5 2010-06-24 108030000 BOND REFUNDING 1 0 1 B MAINE HEALTH & HIGHER EDUCATION FACILITY AUTHORITY 010314384 2016-01-20 7500000 ED EXPANSION AND INPATIENT RENOV 0 0 0 C MAINE HEALTH & HIGHER EDUCATION FACILITY AUTHORITY 010314384 56042RQL9 2017-12-28 48573817 BOND REFUNDING 1 0 1 A 3872756 4202585 390171 4439445 47690 0 1 1 1 B 3000000 7500000 7500000 0 0 1 1 C 2650000 18815225 1316450 19456877 191946 0 1 1 1 A 0 0 0 0 0 0 1 B 0 0 0 0 0 0 1 C 0 0 0 0 0 0 1 A 0 1 0 0 0 0 0 0 0 B 0 0 0 0 0 0 0 0 0 C 0 1 0 0 0 0 0 0 0 A 0 B 0 C 0 FORM 990, PART VI, SECTION B, LINE 11B PRIOR TO FILING THE FORM 990, THE HOSPITAL'S CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER REVIEWED THE FILING IN DETAIL WITH THE HOSPITAL BOARD. THE BOARD FOUND THE REPORT TO BE COMPREHENSIVE AND COMPLETE AND SUPPORTED ITS FILING AS REVIEWED. FORM 990, PART VI, SECTION B, LINE 12C ANNUALLY THE CONFLICT OF INTERESTS DISCLOSURE IS REVIEWED WITH THE MEMBERS OF THE BOARD AND DIRECTORS, WHO THEN SIGN THE DISCLOSURE. FORM 990, PART VI, SECTION B, LINE 15A THE COMPENSATION FOR THE CEO IS ESTABLISHED BY APPROVAL OF THE BOARD OR COMPENSATION COMMITTEE AND UTILIZES INFORMATION FROM INDUSTRY SURVEYS AND FORM 990 INFORMATION FROM OTHER ORGANIZATIONS. FORM 990, PART VI, SECTION C, LINE 19 REDINGTON-FAIRVIEW GENERAL HOSPITAL MAKES ITS GOVERNING DOCUMENTS AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART XI, LINE 9: EFFECT OF ASC 715 -12,440,221. SOMERSET FITNESS CENTER INC 6 COMMERCE DRIVE SKOWHEGAN ME 04976 010524417 FITNESS CENTER ME 246211 72073 REDINGTON FAIRVIEW GENERAL HOSPITAL REDINGTON MEMORIAL HOSPITAL ASSN PO BOX 468 SKOWHEGAN ME 04976 010211154 SOLE SUPPORTING ORGANIZATION OF RFGH ME 501 C (3) 11 (D) N/A 0 FAIRVIEW HOSPITAL INC PO BOX 468 SKOWHEGAN ME 04976 010222130 SOLE SUPPORTING ORGANIZATION OF RFGH ME 501 C (3) 11 (D) N/A 0 SOMERSET SPORTS & FITNESS CENTER 6 COMMERCE DRIVE SKOWHEGAN ME 04976 010524417 FITNESS CENTER ME RFGH 1.00000 0 0 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 REDINGTON MEMORIAL HOSPITAL ASSOCIATION C 864558 CASH FAIRVIEW HOSPITAL INC C 70497 CASH REDINGTON MEMORIAL HOSPITAL ASSOCIATION K 194436 CASH