FAIRBANKS HOSPITAL INC: Form 990, tax year 2021
View the entire original 990 at ProPublica ↗
- Organization
- FAIRBANKS HOSPITAL INC (EIN 35-0811197)
- Tax period
- 2021-01-01 to 2021-12-31
- Filed
- 2022-11-10
- IRS object ID
- 202223149349304102
- Schema version
- 2021v4.2
- Source
- Download XML · Original 990 at ProPublica
Every field in the e-filed return. Faint text is the IRS element name, for citing.
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return | 2022-11-10T11:55:25-06:00 | ReturnTs |
| Tax Period End | 2021-12-31 | TaxPeriodEndDt |
Preparer Firm PreparerFirmGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Firm EIN | 352123203 | PreparerFirmEIN |
Preparer Firm Name PreparerFirmName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | KSM BUSINESS SERVICES INC | BusinessNameLine1Txt |
Preparer US Address PreparerUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | PO BOX 40857 | AddressLine1Txt |
| City | INDIANAPOLIS | CityNm |
| State Abbreviation | IN | StateAbbreviationCd |
| ZIP | 46240 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnTypeCd |
| Tax Period Begin | 2021-01-01 | TaxPeriodBeginDt |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 350811197 | EIN |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | FAIRBANKS HOSPITAL INC | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Control | FAIR | BusinessNameControlTxt |
| Phone | 3178498222 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 8102 CLEARVISTA PARKWAY | AddressLine1Txt |
| City | INDIANAPOLIS | CityNm |
| State Abbreviation | IN | StateAbbreviationCd |
| ZIP | 46256 | ZIPCd |
Business Officer BusinessOfficerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | JASON FAHRLANDER | PersonNm |
| Person Title | EVP COO | PersonTitleTxt |
| Phone | 3176215345 | PhoneNum |
| Signature | 2022-10-26 | SignatureDt |
| Discuss With Paid Preparer | Yes (1) | DiscussWithPaidPreparerInd |
Signing Officer SigningOfficerGrp
Person Full Name PersonFullName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person First | JASON | PersonFirstNm |
| Person Last | FAHRLANDER | PersonLastNm |
| Field | Value | IRS element (for citing) |
|---|---|---|
| SSN | 999009999 | SSN |
Preparer Person PreparerPersonGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Person | CASSE TATE | PreparerPersonNm |
| PTIN | P01271193 | PTIN |
| Phone | 3175802000 | PhoneNum |
| Preparation | 2022-10-24 | PreparationDt |
Additional Filer Information AdditionalFilerInformation
Trusted Customer TrustedCustomerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Trusted Customer | 3 | TrustedCustomerCd |
| Authentication Assurance Level | AAL1 | AuthenticationAssuranceLevelCd |
| Identity Assurance Level | IAL1 | IdentityAssuranceLevelCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax | 2021 | TaxYr |
| Build TS | 2022-09-23 18:48:47Z | BuildTS |
Form 990 IRS990
Doing Business As Name DoingBusinessAsName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | COMMUNITY FAIRBANKS RECOVERY CTR | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Principal Officer | JASON FAHRLANDER | PrincipalOfficerNm |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 8102 CLEARVISTA PARKWAY | AddressLine1Txt |
| City | INDIANAPOLIS | CityNm |
| State Abbreviation | IN | StateAbbreviationCd |
| ZIP | 46256 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | $20,668,322 | GrossReceiptsAmt |
| Group Return For Affiliates | 0 | GroupReturnForAffiliatesInd |
| Organization501c3 | Yes (X) | Organization501c3Ind |
| Website Address | WWW.FAIRBANKSCD.ORG | WebsiteAddressTxt |
| Type Of Organization Corp | Yes (X) | TypeOfOrganizationCorpInd |
| Formation | 1946 | FormationYr |
| Legal Domicile State | IN | LegalDomicileStateCd |
| Activity Or Mission | NONPROFIT ORGANIZATION FOCUSED ON RECOVERY FROM ALCOHOL AND OTHER DRUG PROBLEMS. | ActivityOrMissionDesc |
| Voting Members Governing Body | 13 | VotingMembersGoverningBodyCnt |
| Voting Members Independent | 11 | VotingMembersIndependentCnt |
| Total Employee | 310 | TotalEmployeeCnt |
| Total Volunteers | 157 | TotalVolunteersCnt |
| Total Gross UBI | $0 | TotalGrossUBIAmt |
| Net Unrelated Bus Txbl Incm | $0 | NetUnrelatedBusTxblIncmAmt |
| PY Contributions Grants | $901,300 | PYContributionsGrantsAmt |
| CY Contributions Grants | $728,862 | CYContributionsGrantsAmt |
| PY Program Service Revenue | $15,254,174 | PYProgramServiceRevenueAmt |
| CY Program Service Revenue | $19,751,497 | CYProgramServiceRevenueAmt |
| PY Investment Income | -$3,506 | PYInvestmentIncomeAmt |
| CY Investment Income | -$327,574 | CYInvestmentIncomeAmt |
| PY Other Revenue | $290,190 | PYOtherRevenueAmt |
| CY Other Revenue | $180,448 | CYOtherRevenueAmt |
| PY Total Revenue | $16,442,158 | PYTotalRevenueAmt |
| CY Total Revenue | $20,333,233 | CYTotalRevenueAmt |
| PY Grants And Similar Paid | $460,961 | PYGrantsAndSimilarPaidAmt |
| CY Grants And Similar Paid | $0 | CYGrantsAndSimilarPaidAmt |
| PY Benefits Paid To Members | $0 | PYBenefitsPaidToMembersAmt |
| CY Benefits Paid To Members | $0 | CYBenefitsPaidToMembersAmt |
| PY Salaries Comp Emp Bnft Paid | $15,895,281 | PYSalariesCompEmpBnftPaidAmt |
| CY Salaries Comp Emp Bnft Paid | $16,292,691 | CYSalariesCompEmpBnftPaidAmt |
| PY Total Prof Fndrsng Expns | $0 | PYTotalProfFndrsngExpnsAmt |
| CY Total Prof Fndrsng Expns | $0 | CYTotalProfFndrsngExpnsAmt |
| CY Total Fundraising Expense | $0 | CYTotalFundraisingExpenseAmt |
| PY Other Expenses | $6,797,374 | PYOtherExpensesAmt |
| CY Other Expenses | $8,491,843 | CYOtherExpensesAmt |
| PY Total Expenses | $23,153,616 | PYTotalExpensesAmt |
| CY Total Expenses | $24,784,534 | CYTotalExpensesAmt |
| PY Revenues Less Expenses | -$6,711,458 | PYRevenuesLessExpensesAmt |
| CY Revenues Less Expenses | -$4,451,301 | CYRevenuesLessExpensesAmt |
| Total Assets BOY | $20,998,245 | TotalAssetsBOYAmt |
| Total Assets EOY | $19,560,027 | TotalAssetsEOYAmt |
| Total Liabilities BOY | $7,552,403 | TotalLiabilitiesBOYAmt |
| Total Liabilities EOY | $10,644,799 | TotalLiabilitiesEOYAmt |
| Net Assets Or Fund Balances BOY | $13,445,842 | NetAssetsOrFundBalancesBOYAmt |
| Net Assets Or Fund Balances EOY | $8,915,228 | NetAssetsOrFundBalancesEOYAmt |
| Info In Schedule O Part III | Yes (X) | InfoInScheduleOPartIIIInd |
| Mission | FAIRBANKS IS A NONPROFIT ORGANIZATION FOCUSED ON RECOVERY FROM ALCOHOL AND OTHER DRUG PROBLEMS, SERVING AS A RESOURCE TO IMPROVE THE WELL-BEING OF INDIVIDUALS, FAMILIES AND COMMUNITIES BY OFFERING HOPE AND SUPPORT THROUGH ITS PROGRAMS AND SERVICES. | MissionDesc |
| Significant New Program Srvc | 0 | SignificantNewProgramSrvcInd |
| Significant Change | 0 | SignificantChangeInd |
| Expense | $4,950,509 | ExpenseAmt |
| Revenue | $8,232,514 | RevenueAmt |
| Desc | ADULT INPATIENT SERVICES CONSISTING OF DETOXIFICATION AND REHABILIATION SERVICES. THE DETOXIFICATION PHASE IS A MEDICALLY MANAGED LEVEL OF CARE WHERE THE EXTENT OF THE PATIENT'S ADDICTION IS DETERMINED AND THE PHYSICAL AND PSYCHOLOGICAL IMPACT OF THAT ADDICTION IS ASSESSED AND THE APPROPRIATE TREATMENT COURSE IS INITIATED. FOR THE CURRENT YEAR, FAIRBANKS HOSPITAL HAD 8,535 ADULT DETOX PATIENT DAYS.THE REHABILITATION PHASE OCCURS WHEN FURTHER INPATIENT STABILIZATION/TREATMENT IS NEEDED AND REQUIRED CONTINUED MEDICAL SUPERVISION. THE TREATMENT PROCESS IS MULTI-DISCIPLINARY AND GROUP ORIENTED. FOR THE CURRENT YEAR, THE HOSPITAL HAD 389 ADULT REHAB PATIENT DAYS. | Desc |
Prog Srvc Accom Acty2 ProgSrvcAccomActy2Grp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | $1,427,814 | ExpenseAmt |
| Revenue | $3,724,581 | RevenueAmt |
| Desc | ADULT OUTPATIENT SERVICES PROGRAM CONSISTING OF PARTIAL HOSPITALIZATION (PHP) AND INTENSIVE OUTPATIENT PROGRAM (IOP). THE PHP PROGRAM IS SIX TO SEVEN HOURS PER DAY MONDAY THROUGH FRIDAY AND IS A MULTI-DISCIPLINARY AND GROUP ORIENTED TREATMENT PROGRAM. THE PROGRAM CONTAINS EVALUATION AND EDUCATION. IT ALLOWS THE PATIENT TO EXPERIENCE LIFE ON THE "OUTSIDE" WHILE BEING INVOLVED IN A VERY INTENSE LEVEL OF TREATMENT. FOR THE CURRENT YEAR, THE HOSPITAL HAD 4,507 PHP VISITS.IOP IS AVAILABLE TO THOSE WHOSE ADDICTION IS NOT SO SEVERE AS TO REQUIRE INPATIENT OR PHP SERVICES. THE PATIENTS MUST DEMONSTRATE THE ABILITY TO REMAIN DRUG-FREE DURING THE ENTIRE TREATMENT COURSE AND INDICATE A WILLINGNESS TO BECOME INVOLVED IN A 12-STEP PROGRAM. IOP PATIENTS GENERALLY MEET FOR THREE HOURS, THREE TIMES PER WEEK. IOP OFFERS EDUCATION AND GROUP THERAPY. FOR THE CURRENT YEAR, THE HOSPITAL HAD 7,739 VISITS PLUS 2,408 VIRTUAL IOP VISITS.LEVEL 1 OUTPATIENT - IN ALIGNMENT WITH THE AMERICAN SOCIETY FOR ADDICTION MEDICINE (ASAM), FAIRBANKS CONSIDERS PATIENTS WHOSE SEVERITY OF SUBSTANCE USE IS MILD AND CAUSES MINIMAL INTERRUPTION IN THEIR FUNCTIONING AS BEING BEST SUITED FOR LEVEL 1 OP SERVICES. THESE INDIVIDUALS MAY PRESENT WITH MILD, CO-OCCURRING SUBSTANCE ABUSE AND MENTAL HEALTH AND/OR PHYSICAL HEALTH CONDITIONS. THEY MAY ALREADY BE RECEIVING SERVICES FOR THESE OTHER CO-OCCURING CONDITIONS, BUT NEED MORE EDUCATION, SUPPORT AND TREATMENT FOR ISSUES RELATED TO THEIR SUBSTANCE USE. ADDITIONALLY, LEVEL 1 MAY BE APPROPRIATE FOR INDIVIDUALS WHO ARE NOT INTERESTED IN RECOVERY, BUT ARE MANDATED INTO TREATMENT. THEY MAY OR MAY NOT HAVE COMPLETED AN EDUCATION COURSE, BUT APPEAR TO NEED MORE THAN JUST EDUCATION AS INDICATED BY THEIR USE OR SERVICE HISTORY. INDIVIDUALS WHO NEED MORE THAN JUST EDUCATION TO ENHANCE THEIR MOTIVATION OR TO CREATE AMBIVALENCE MAY ALSO BENEFIT FROM THIS LEVEL OF CARE. AT THE SAME TIME, INDIVIDUALS WHO ARE IN EARLY RECOVERY AND VIEW TREATMENT AS POTENTIALLY HELPFUL AND ARE ENTERING TREATMENT FOR THE FIRST TIME WILL BENEFIT FROM LEVEL 1. PATIENTS IN THIS LEVEL OF CARE MAY BE RECEIVING MEDICATION ASSISTED TREATMENT (MAT) SERVICES AND/OR OTHER THERAPIES DUE TO THEIR SUBSTANCE USE INCLUDING PATIENTS WHO NEED A STEP DOWN FROM IOP WHOM THE TREATMENT TEAM FINDS HAVE CONTINUED THERAPEUTIC NEEDS BEYOND THE SUPPORT OF AN AFTERCARE PROGRAM. FOR THE CURRENT YEAR, THE HOSPITAL HAD 216 ADULT LEVEL 1 VISITS PLUS 2,182 VIRTUAL LEVEL 1 VISITS. | Desc |
Prog Srvc Accom Acty3 ProgSrvcAccomActy3Grp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | $888,241 | ExpenseAmt |
| Revenue | $3,962,890 | RevenueAmt |
| Desc | THE ADULT RESIDENTIAL PROGRAM IS FOR THE PATIENT WHO REQUIRES A RESTRICTIVE ENVIRONMENT TO ABSTAIN FROM USING BUT WHO IS MEDICALLY STABLE. THE PATIENT PARTICIPATES IN NO LESS THAN FOUR HOURS OF THERAPY DAILY AND NURSING CARE IS PROVIDED, IF NEEDED. FOR THE CURRENT YEAR, THE HOSPITAL HAD 7,300 ADULT RESIDENTIAL PATIENT DAYS. | Desc |
Prog Srvc Accom Acty Other ProgSrvcAccomActyOtherGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | $9,983,519 | ExpenseAmt |
| Revenue | $3,854,637 | RevenueAmt |
| Desc | ADOLESCENT OUTPATIENTS SERVICES PROGRAM SERVED 645 IOP VISITS DURING THE CURRENT YEAR. FAIRBANKS HOSPITAL PROVIDED 2,759 PATIENT DAYS AT LAVERNA LODGE FOR MEN, 368 DAYS AT LAVERNA LODGE FOR WOMEN, AND 15,691 PATIENT DAYS AT RECOVERY HOUSING DURING THE CURRENT YEAR.IN ADDITION TO THE OTHER ACCOMPLISHMENTS, FAIRBANKS WORKED TO ADDRESS THE NEEDS OF THE COMMUNITY USING SEVERAL DIFFERENT STRATEGIES DEVELOPED TO REACH THE COMMUNITY VIRTUALLY DUE TO COVID-19 RESTRICTIONS IN PLACE. THE ADOLESCENT COUNSELING TEAM AT FAIRBANKS DEVELOPED A SERIES OF VIDEOS TO RAISE AWARENESS OF EXISTING ADOLESCENT PREVENTION AND TREATMENT PROGRAMS AVAILABLE FOR STUDENTS AND TEENS WHO MAY BE STRUGGLING WITH ADDICTION AND DECLINING MENTAL HEALTH DUE TO THE PANDEMIC. THESE VIDEOS WERE SHARED ON SOCIAL MEDIA AND YOUTUBE AND COVERED TOPICS SUCH AS COPING WITH ISOLATION, DEPRESSION AND ANXIETY AND HOW AND WHERE TO SEEK TREATMENT. THESE VIDEOS WERE ABLE TO REACH OVER 20,950 VIEWERS. IN ADDITION TO PROMOTION OF ADOLESCENT PROGRAMS, FAIRBANKS ALSO LAUNCHED THE FAMILY SUPPORT CENTER IN 2020. THE FAMILY SUPPORT CENTER IS DESIGNED TO HELP FAMILIES AND FRIENDS GET ANSWERS TO THE MANY QUESTIONS THEY MAY HAVE WHEN LEARNING ABOUT - AND TRYING TO UNDERSTAND - SUBSTANCE-ABUSE DISORDERS. DUE TO THE PANDEMIC, THE PROGRAM OPERATES VIRTUALLY AND IS SERVING AN EVEN GREATER NEED NOW THAT MORE HOOSIERS ARE STRUGGLING WITH ADDICTION DUE TO THE STRESS FROM THE PANDEMIC. | Desc |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Other Prog Srvc Expense | $9,983,519 | TotalOtherProgSrvcExpenseAmt |
| Total Other Prog Srvc Revenue | $3,854,637 | TotalOtherProgSrvcRevenueAmt |
| Total Program Service Expenses | $17,250,083 | TotalProgramServiceExpensesAmt |
| Described In Section501c3 | Yes (1) | DescribedInSection501c3Ind |
| Schedule B Required | Yes (1) | ScheduleBRequiredInd |
| Political Campaign Acty | 0 | PoliticalCampaignActyInd |
| Lobbying Activities | 0 | LobbyingActivitiesInd |
| Subject To Proxy Tax | 0 | SubjectToProxyTaxInd |
| Donor Advised Fund | 0 | DonorAdvisedFundInd |
| Conservation Easements | 0 | ConservationEasementsInd |
| Collections Of Art | 0 | CollectionsOfArtInd |
| Credit Counseling | 0 | CreditCounselingInd |
| Donor Rstr Or Quasi Endowments | 0 | DonorRstrOrQuasiEndowmentsInd |
| Report Land Building Equipment | Yes (1) | ReportLandBuildingEquipmentInd |
| Report Investments Other Sec | 0 | ReportInvestmentsOtherSecInd |
| Report Program Related Invst | 0 | ReportProgramRelatedInvstInd |
| Report Other Assets | 0 | ReportOtherAssetsInd |
| Report Other Liabilities | Yes (1) | ReportOtherLiabilitiesInd |
| Include FIN48 Footnote | 0 | IncludeFIN48FootnoteInd |
| Independent Audit Fincl Stmt | 0 | IndependentAuditFinclStmtInd |
| Consolidated Audit Fincl Stmt | Yes (1) | ConsolidatedAuditFinclStmtInd |
| School Operating | 0 | SchoolOperatingInd |
| Foreign Office | 0 | ForeignOfficeInd |
| Foreign Activities | 0 | ForeignActivitiesInd |
| More Than5000 K To Org | 0 | MoreThan5000KToOrgInd |
| More Than5000 K To Individuals | 0 | MoreThan5000KToIndividualsInd |
| Professional Fundraising | 0 | ProfessionalFundraisingInd |
| Fundraising Activities | 0 | FundraisingActivitiesInd |
| Gaming Activities | 0 | GamingActivitiesInd |
| Operate Hospital | 0 | OperateHospitalInd |
| Grants To Organizations | 0 | GrantsToOrganizationsInd |
| Grants To Individuals | 0 | GrantsToIndividualsInd |
| Schedule J Required | Yes (1) | ScheduleJRequiredInd |
| Tax Exempt Bonds | 0 | TaxExemptBondsInd |
| Engaged In Excess Benefit Trans | 0 | EngagedInExcessBenefitTransInd |
| PY Excess Benefit Trans | 0 | PYExcessBenefitTransInd |
| Loan Outstanding | 0 | LoanOutstandingInd |
| Grant To Related Person | 0 | GrantToRelatedPersonInd |
| Business Rln With Org Mem | 0 | BusinessRlnWithOrgMemInd |
| Business Rln With Fam Mem | 0 | BusinessRlnWithFamMemInd |
| Business Rln With35 Ctrl Ent | 0 | BusinessRlnWith35CtrlEntInd |
| Deductible Non Cash Contri | 0 | DeductibleNonCashContriInd |
| Deductible Art Contribution | 0 | DeductibleArtContributionInd |
| Terminate Operations | 0 | TerminateOperationsInd |
| Partial Liquidation | 0 | PartialLiquidationInd |
| Disregarded Entity | 0 | DisregardedEntityInd |
| Related Entity | Yes (1) | RelatedEntityInd |
| Related Organization Ctrl Ent | Yes (1) | RelatedOrganizationCtrlEntInd |
| Transaction With Control Ent | Yes (1) | TransactionWithControlEntInd |
| Trnsfr Exmpt Non Chrtbl Rltd Org | 0 | TrnsfrExmptNonChrtblRltdOrgInd |
| Activities Conducted Prtshp | 0 | ActivitiesConductedPrtshpInd |
| Schedule O Required | Yes (1) | ScheduleORequiredInd |
| IRP Document | 0 | IRPDocumentCnt |
| IRP Document W2 G | 0 | IRPDocumentW2GCnt |
| Backup Wthld Compliance | Yes (1) | BackupWthldComplianceInd |
| Employee | 310 | EmployeeCnt |
| Employment Tax Returns Filed | Yes (1) | EmploymentTaxReturnsFiledInd |
| Unrelated Bus Incm Over Limit | 0 | UnrelatedBusIncmOverLimitInd |
| Foreign Financial Account | 0 | ForeignFinancialAccountInd |
| Prohibited Tax Shelter Trans | 0 | ProhibitedTaxShelterTransInd |
| Taxable Party Notification | 0 | TaxablePartyNotificationInd |
| Nondeductible Contributions | 0 | NondeductibleContributionsInd |
| Quid Pro Quo Contributions | 0 | QuidProQuoContributionsInd |
| Form8282 Property Disposed Of | 0 | Form8282PropertyDisposedOfInd |
| Rcv Fnds To Pay Prsnl Bnft Cntrct | 0 | RcvFndsToPayPrsnlBnftCntrctInd |
| Pay Premiums Prsnl Bnft Cntrct | 0 | PayPremiumsPrsnlBnftCntrctInd |
| Indoor Tanning Services | 0 | IndoorTanningServicesInd |
| Subj To Tax Rmnrtn Ex Prcht Pymt | 0 | SubjToTaxRmnrtnExPrchtPymtInd |
| Subject To Excs Tax Net Invst Inc | 0 | SubjectToExcsTaxNetInvstIncInd |
| Info In Schedule O Part VI | Yes (X) | InfoInScheduleOPartVIInd |
| Governing Body Voting Members | 13 | GoverningBodyVotingMembersCnt |
| Independent Voting Member | 11 | IndependentVotingMemberCnt |
| Family Or Business Rln | Yes (1) | FamilyOrBusinessRlnInd |
| Delegation Of Mgmt Duties | Yes (1) | DelegationOfMgmtDutiesInd |
| Change To Org Documents | 0 | ChangeToOrgDocumentsInd |
| Material Diversion Or Misuse | 0 | MaterialDiversionOrMisuseInd |
| Members Or Stockholders | Yes (1) | MembersOrStockholdersInd |
| Election Of Board Members | Yes (1) | ElectionOfBoardMembersInd |
| Decisions Subject To Approva | Yes (1) | DecisionsSubjectToApprovaInd |
| Minutes Of Governing Body | Yes (1) | MinutesOfGoverningBodyInd |
| Minutes Of Committees | Yes (1) | MinutesOfCommitteesInd |
| Officer Mailing Address | 0 | OfficerMailingAddressInd |
| Local Chapters | 0 | LocalChaptersInd |
| Form990 Provided To Gvrn Body | 0 | Form990ProvidedToGvrnBodyInd |
| Conflict Of Interest Policy | Yes (1) | ConflictOfInterestPolicyInd |
| Annual Disclosure Covered Prsn | Yes (1) | AnnualDisclosureCoveredPrsnInd |
| Regular Monitoring Enfrc | Yes (1) | RegularMonitoringEnfrcInd |
| Whistleblower Policy | Yes (1) | WhistleblowerPolicyInd |
| Document Retention Policy | Yes (1) | DocumentRetentionPolicyInd |
| Compensation Process CEO | Yes (1) | CompensationProcessCEOInd |
| Compensation Process Other | Yes (1) | CompensationProcessOtherInd |
| Investment In Joint Venture | 0 | InvestmentInJointVentureInd |
| States Where Copy Of Return Is Fld | IN | StatesWhereCopyOfReturnIsFldCd |
| Upon Request | Yes (X) | UponRequestInd |
Books In Care Of Detail BooksInCareOfDetail
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | BRIAN MCCONNELL | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Phone | 3173554212 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 8180 CLEARVISTA PARKWAY SUITE 200 | AddressLine1Txt |
| City | INDIANAPOLIS | CityNm |
| State Abbreviation | IN | StateAbbreviationCd |
| ZIP | 46256 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part VII | Yes (X) | InfoInScheduleOPartVIIInd |
Form990 Part VII Section A Form990PartVIISectionAGrp (24 entries)
| TitleTitleTxt | Average Hours Per WeekAverageHoursPerWeekRt | Average Hours Per Week Rltd OrgAverageHoursPerWeekRltdOrgRt | Individual Trustee Or DirectorIndividualTrusteeOrDirectorInd | Reportable Comp From OrgReportableCompFromOrgAmt | Reportable Comp From Rltd OrgReportableCompFromRltdOrgAmt | Other CompensationOtherCompensationAmt | OfficerOfficerInd | Highest Compensated EmployeeHighestCompensatedEmployeeInd |
|---|---|---|---|---|---|---|---|---|
| JASON FAHRLANDER | ||||||||
| DIRECTOR | 1.00 | 54.00 | Yes (X) | $0 | $789,889 | $401,491 | ||
| ANDREW SONDERMAN MD | ||||||||
| DIRECTOR STARTING FEB 2021 | 40.00 | 0.00 | Yes (X) | $348,724 | $0 | $76,826 | ||
| JASON LANDIS | ||||||||
| VP-FINANCE | 5.00 | 45.00 | $0 | $246,877 | $70,551 | Yes (X) | ||
| THERESA ANDERSON RN | ||||||||
| INTERIM CEO THROUGH AUG 2021 | 36.00 | 4.00 | Yes (X) | $180,638 | $0 | $58,262 | Yes (X) | |
| CATHY BOGGS | ||||||||
| EXECUTIVE DIRECTOR AND ADMINISTRATOR | 30.00 | 10.00 | $0 | $178,092 | $57,610 | Yes (X) | ||
| ROBIN PARSON | ||||||||
| DIRECTOR-BEHAVIORAL HEALTH | 40.00 | 0.00 | $133,064 | $0 | $34,136 | Yes (X) | ||
| DANA PINKOWSKI | ||||||||
| NURSE | 40.00 | 0.00 | $129,956 | $0 | $30,236 | Yes (X) | ||
| JUDIE HUFF | ||||||||
| PATIENT CARE COORDINATOR | 40.00 | 0.00 | $146,486 | $0 | $11,432 | Yes (X) | ||
| RACHEL BOTKIN | ||||||||
| APP | 40.00 | 0.00 | $125,796 | $0 | $28,590 | Yes (X) | ||
| MARJORIE COMBELLICK | ||||||||
| NURSE PRACTITIONER | 40.00 | 0.00 | $130,396 | $0 | $16,144 | Yes (X) | ||
| PATRICK CARR | ||||||||
| DIRECTOR | 1.00 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| DAVID CORBITT | ||||||||
| SECRETARY | 1.00 | 0.00 | Yes (X) | $0 | $0 | $0 | Yes (X) | |
| BILLIE FOUTS | ||||||||
| DIRECTOR | 1.00 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| GREG FULK | ||||||||
| DIRECTOR | 1.00 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| SWATI GUNALE | ||||||||
| DIRECTOR | 1.00 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| DAVID HERZOG | ||||||||
| VICE CHAIRMAN | 1.00 | 0.00 | Yes (X) | $0 | $0 | $0 | Yes (X) | |
| MARISSA MANLOVE | ||||||||
| DIRECTOR | 1.00 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| ANN MERKEL | ||||||||
| DIRECTOR THROUGH MAY 2021 | 1.00 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| DAVID MOORE | ||||||||
| DIRECTOR STARTING APRIL 2021 | 1.00 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| KEVIN MURPHY | ||||||||
| DIRECTOR | 1.00 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| MATTHEW NEFF | ||||||||
| CHAIRMAN | 1.00 | 0.00 | Yes (X) | $0 | $0 | $0 | Yes (X) | |
| ELIZABETH SMITH | ||||||||
| DIRECTOR THROUGH SEPT 2021 | 1.00 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| ADRIENNE TAKACS | ||||||||
| DIRECTOR THROUGH FEB 2021 | 1.00 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| CONRAD WONG MD | ||||||||
| DIRECTOR STARTING APRIL 2021 | 1.00 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | $1,195,060 | TotalReportableCompFromOrgAmt |
| Tot Reportable Comp Rltd Org | $1,214,858 | TotReportableCompRltdOrgAmt |
| Total Other Compensation | $785,278 | TotalOtherCompensationAmt |
| Indiv Rcvd Greater Than100 K | 13 | IndivRcvdGreaterThan100KCnt |
| Former Ofcr Employees Listed | 0 | FormerOfcrEmployeesListedInd |
| Total Comp Greater Than150 K | Yes (1) | TotalCompGreaterThan150KInd |
| Compensation From Other Srcs | 0 | CompensationFromOtherSrcsInd |
Contractor Compensation ContractorCompensationGrp (4 entries)
| Address Line1ContractorAddress/USAddress/AddressLine1Txt | CityContractorAddress/USAddress/CityNm | State AbbreviationContractorAddress/USAddress/StateAbbreviationCd | ZIPContractorAddress/USAddress/ZIPCd | ServicesServicesDesc | CompensationCompensationAmt |
|---|---|---|---|---|---|
| ARAMARK FOOD SERVICES AND SUPPORT SERVIC | |||||
| 27310 NETWORK PLACE | CHICAGO | IL | 60673 | FOOD SERVICE | $556,923 |
| ELLIS MECHANICAL AND ELECTRICAL | |||||
| 2929 BLUFF ROAD | INDIANAPOLIS | IN | 46225 | ELECTRICAL SERVICE | $216,623 |
| BLAKLEY'S CORPORATION | |||||
| 8060 EAST 88TH ST | INDIANAPOLIS | IN | 46256 | CONTRACTOR | $112,620 |
| AYA HEALTHCARE INC | |||||
| 5930 CORNERSTONE COURT WEST SUITE 3 | SAN DIEGO | CA | 92121 | TEMPORARY STAFFING | $107,990 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cntrct Rcvd Greater Than100 K | 4 | CntrctRcvdGreaterThan100KCnt |
| Related Organizations | $728,862 | RelatedOrganizationsAmt |
| Total Contributions | $728,862 | TotalContributionsAmt |
Program Service Revenue ProgramServiceRevenueGrp (2 entries)
| DescDesc | BusinessBusinessCd | Total Revenue ColumnTotalRevenueColumnAmt | Related Or Exempt Func IncomeRelatedOrExemptFuncIncomeAmt |
|---|---|---|---|
| PATIENT SERVICE REVENUE | 621300 | $19,296,467 | $19,296,467 |
| RENT | 531120 | $455,030 | $455,030 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | $19,751,497 | TotalProgramServiceRevenueAmt |
Investment Income InvestmentIncomeGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $6,915 | TotalRevenueColumnAmt |
| Exclusion | $6,915 | ExclusionAmt |
Gross Amount Sales Assets GrossAmountSalesAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | $600 | OtherAmt |
Less Cost Oth Basis Sales Expnss LessCostOthBasisSalesExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | $335,089 | OtherAmt |
Gain Or Loss GainOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | -$334,489 | OtherAmt |
Net Gain Or Loss Investments NetGainOrLossInvestmentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | -$334,489 | TotalRevenueColumnAmt |
| Exclusion | -$334,489 | ExclusionAmt |
Other Revenue Misc OtherRevenueMiscGrp (3 entries)
| DescDesc | BusinessBusinessCd | Total Revenue ColumnTotalRevenueColumnAmt | ExclusionExclusionAmt | Related Or Exempt Func IncomeRelatedOrExemptFuncIncomeAmt |
|---|---|---|---|---|
| CAFETERIA REVENUE | 624100 | $94,541 | $94,541 | |
| GIFT SHOP REVENUE | 900099 | $62,782 | $62,782 | |
| CONFERENCE ROOM RENT | 531110 | $539 | $539 |
Miscellaneous Revenue MiscellaneousRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $22,586 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $22,586 | RelatedOrExemptFuncIncomeAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Revenue Total | $180,448 | OtherRevenueTotalAmt |
Total Revenue TotalRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $20,333,233 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $19,774,622 | RelatedOrExemptFuncIncomeAmt |
| Unrelated Business Revenue | $0 | UnrelatedBusinessRevenueAmt |
| Exclusion | -$170,251 | ExclusionAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part IX | Yes (X) | InfoInScheduleOPartIXInd |
Comp Current Ofcr Directors CompCurrentOfcrDirectorsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $664,450 | TotalAmt |
| Program Services | $574,901 | ProgramServicesAmt |
| Management And General | $89,549 | ManagementAndGeneralAmt |
Other Salaries And Wages OtherSalariesAndWagesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $12,369,245 | TotalAmt |
| Program Services | $10,702,227 | ProgramServicesAmt |
| Management And General | $1,667,018 | ManagementAndGeneralAmt |
Pension Plan Contributions PensionPlanContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $453,124 | TotalAmt |
| Program Services | $385,891 | ProgramServicesAmt |
| Management And General | $67,233 | ManagementAndGeneralAmt |
Other Employee Benefits OtherEmployeeBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,896,966 | TotalAmt |
| Program Services | $1,641,310 | ProgramServicesAmt |
| Management And General | $255,656 | ManagementAndGeneralAmt |
Payroll Taxes PayrollTaxesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $908,906 | TotalAmt |
| Program Services | $784,715 | ProgramServicesAmt |
| Management And General | $124,191 | ManagementAndGeneralAmt |
Fees For Services Legal FeesForServicesLegalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $7,459 | TotalAmt |
| Management And General | $7,459 | ManagementAndGeneralAmt |
Fees For Services Other FeesForServicesOtherGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $5,172,862 | TotalAmt |
| Program Services | $641,655 | ProgramServicesAmt |
| Management And General | $4,531,207 | ManagementAndGeneralAmt |
Advertising AdvertisingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $239 | TotalAmt |
| Program Services | $30 | ProgramServicesAmt |
| Management And General | $209 | ManagementAndGeneralAmt |
Office Expenses OfficeExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,050,411 | TotalAmt |
| Program Services | $772,006 | ProgramServicesAmt |
| Management And General | $278,405 | ManagementAndGeneralAmt |
Information Technology InformationTechnologyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $27,718 | TotalAmt |
| Program Services | $13,408 | ProgramServicesAmt |
| Management And General | $14,310 | ManagementAndGeneralAmt |
Occupancy OccupancyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,103,739 | TotalAmt |
| Program Services | $954,987 | ProgramServicesAmt |
| Management And General | $148,752 | ManagementAndGeneralAmt |
Travel TravelGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $22,889 | TotalAmt |
| Program Services | $16,337 | ProgramServicesAmt |
| Management And General | $6,552 | ManagementAndGeneralAmt |
Conferences Meetings ConferencesMeetingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,850 | TotalAmt |
| Program Services | $1,850 | ProgramServicesAmt |
Depreciation Depletion DepreciationDepletionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $696,324 | TotalAmt |
| Program Services | $466,126 | ProgramServicesAmt |
| Management And General | $230,198 | ManagementAndGeneralAmt |
Insurance InsuranceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $97,583 | TotalAmt |
| Program Services | $2,802 | ProgramServicesAmt |
| Management And General | $94,781 | ManagementAndGeneralAmt |
Other Expenses OtherExpensesGrp (4 entries)
| DescDesc | TotalTotalAmt | Program ServicesProgramServicesAmt | Management And GeneralManagementAndGeneralAmt |
|---|---|---|---|
| MEDICAL EXPENSES | $284,341 | $284,341 | |
| DUES & LICENSES | $11,067 | $2,317 | $8,750 |
| LICENSING & INSPECTION | $6,322 | $2,281 | $4,041 |
| MEALS & ENTERTAINMENT | $5,984 | $2,159 | $3,825 |
All Other Expenses AllOtherExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $3,055 | TotalAmt |
| Program Services | $740 | ProgramServicesAmt |
| Management And General | $2,315 | ManagementAndGeneralAmt |
Total Functional Expenses TotalFunctionalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $24,784,534 | TotalAmt |
| Program Services | $17,250,083 | ProgramServicesAmt |
| Management And General | $7,534,451 | ManagementAndGeneralAmt |
| Fundraising | $0 | FundraisingAmt |
Cash Non Interest Bearing CashNonInterestBearingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,916,494 | BOYAmt |
| EOY | $1,546,224 | EOYAmt |
Accounts Receivable AccountsReceivableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,694,243 | BOYAmt |
| EOY | $1,978,758 | EOYAmt |
Oth Notes Loans Receivable Net OthNotesLoansReceivableNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| EOY | $50,000 | EOYAmt |
Inventories For Sale Or Use InventoriesForSaleOrUseGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $14,014 | BOYAmt |
| EOY | $11,714 | EOYAmt |
Prepaid Expenses Defrd Charges PrepaidExpensesDefrdChargesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $62,030 | BOYAmt |
| EOY | $45,743 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Bldg Equip Cost Or Other Bss | $16,959,711 | LandBldgEquipCostOrOtherBssAmt |
| Land Bldg Equip Accum Deprec | $1,322,131 | LandBldgEquipAccumDeprecAmt |
Land Bldg Equip Basis Net LandBldgEquipBasisNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $16,145,223 | BOYAmt |
| EOY | $15,637,580 | EOYAmt |
Intangible Assets IntangibleAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $53,722 | BOYAmt |
| EOY | $0 | EOYAmt |
Other Assets Total OtherAssetsTotalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $112,519 | BOYAmt |
| EOY | $290,008 | EOYAmt |
Total Assets TotalAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $20,998,245 | BOYAmt |
| EOY | $19,560,027 | EOYAmt |
Accounts Payable Accr Expnss AccountsPayableAccrExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $280,083 | BOYAmt |
| EOY | $62,338 | EOYAmt |
Deferred Revenue DeferredRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| EOY | $42,488 | EOYAmt |
Other Liabilities OtherLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $7,272,320 | BOYAmt |
| EOY | $10,539,973 | EOYAmt |
Total Liabilities TotalLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $7,552,403 | BOYAmt |
| EOY | $10,644,799 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Organization Follows FASB117 | Yes (X) | OrganizationFollowsFASB117Ind |
No Donor Restriction Net Assets NoDonorRestrictionNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $13,445,842 | BOYAmt |
| EOY | $8,915,228 | EOYAmt |
Total Net Assets Fund Balance TotalNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $13,445,842 | BOYAmt |
| EOY | $8,915,228 | EOYAmt |
Tot Liab Net Assets Fund Balance TotLiabNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $20,998,245 | BOYAmt |
| EOY | $19,560,027 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part XI | Yes (X) | InfoInScheduleOPartXIInd |
| Reconcilation Revenue Expnss | -$4,451,301 | ReconcilationRevenueExpnssAmt |
| Other Changes In Net Assets | -$79,313 | OtherChangesInNetAssetsAmt |
| Method Of Accounting Accrual | Yes (X) | MethodOfAccountingAccrualInd |
| Accountant Compile Or Review | 0 | AccountantCompileOrReviewInd |
| FS Audited | Yes (1) | FSAuditedInd |
FS Audited Basis FSAuditedBasisGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Consolidated Basis Fincl Stmt | Yes (X) | ConsolidatedBasisFinclStmtInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Audit Committee | Yes (1) | AuditCommitteeInd |
| Federal Grant Audit Required | 0 | FederalGrantAuditRequiredInd |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Hospital | Yes (X) | HospitalInd |
Form990 Schedule A Part VI Form990ScheduleAPartVIGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | SCHEDULE A, PART 1, LINE 3: | FormAndLineReferenceDesc |
| Explanation | FAIRBANKS HOSPITAL, INC. IS A PRIVATE MENTAL HEALTH INSTITUTION AND CERTIFIED AS AN ADDICTIONS SERVICE PROVIDER. IT HAS BEEN DETERMINED BY THE IRS TO BE A PUBLIC CHARITY UNDER CODE SECTION 170(B)(1)(A)(III) BECAUSE IT HAS AS A PURPOSE THE PROVISION OF MEDICAL OR HOSPITAL CARE. FAIRBANKS HOSPITAL IS ALSO RECOGNIZED BY THE CENTERS FOR MEDICAID AND MEDICARE AS A HOSPITAL-GENERAL ON FORM 855. HOWEVER, FAIRBANKS HOSPITAL IS NOT REQUIRED TO COMPLETE SCHEDULE H BECAUSE IT IS NOT REQUIRED TO BE, NOR IS IT, LICENSED OR REGISTERED BY THE STATE OF INDIANA AS A "HOSPITAL." CODE SECTION 501(R) AND THE INSTRUCTIONS FOR SCHEDULE H PROVIDE THAT ONLY ORGANIZATIONS THAT OPERATE AT LEAST ONE FACILITY THAT IS, OR IS REQUIRED TO BE, LICENSED, REGISTERED OR SIMILARLY RECOGNIZED BY A STATE AS A HOSPITAL ARE REQUIRED TO COMPLETE SCHEDULE H. | ExplanationTxt |
Schedule B IRS990ScheduleB
Contributor Information ContributorInformationGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Contributor | RESTRICTED | ContributorNum |
Contributor Business Name ContributorBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | RESTRICTED | BusinessNameLine1 |
Contributor US Address ContributorUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | RESTRICTED | AddressLine1 |
| Address Line2 | RESTRICTED | AddressLine2 |
| City | RESTRICTED | City |
| State | RESTRICTED | State |
| ZIP Code | RESTRICTED | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Contributions | RESTRICTED | TotalContributionsAmt |
Schedule D IRS990ScheduleD
Land LandGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $150,000 | OtherCostOrOtherBasisAmt |
| Book Value | $150,000 | BookValueAmt |
Buildings BuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $15,896,126 | OtherCostOrOtherBasisAmt |
| Depreciation | $872,232 | DepreciationAmt |
| Book Value | $15,023,894 | BookValueAmt |
Equipment EquipmentGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $794,862 | OtherCostOrOtherBasisAmt |
| Depreciation | $409,119 | DepreciationAmt |
| Book Value | $385,743 | BookValueAmt |
Other Land Buildings OtherLandBuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $118,723 | OtherCostOrOtherBasisAmt |
| Depreciation | $40,780 | DepreciationAmt |
| Book Value | $77,943 | BookValueAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Land Buildings | $15,637,580 | TotalBookValueLandBuildingsAmt |
Other Liabilities Org OtherLiabilitiesOrgGrp (3 entries)
| DescDesc | AmtAmt |
|---|---|
| RIGHT-OF-USE LIABILITIES | $127,225 |
| DUE TO AFFILIATED ENTITIES | $10,287,748 |
| THIRD PARTY SETTLEMENTS | $125,000 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Liability | $10,539,973 | TotalLiabilityAmt |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Severance Payment | 0 | SeverancePaymentInd |
| Supplemental Nonqual Rtr Plan | Yes (1) | SupplementalNonqualRtrPlanInd |
| Equity Based Comp Arrngm | 0 | EquityBasedCompArrngmInd |
| Comp Based On Revenue Of Flng Org | 0 | CompBasedOnRevenueOfFlngOrgInd |
| Comp Bsd On Rev Related Orgs | 0 | CompBsdOnRevRelatedOrgsInd |
| Comp Bsd Net Earns Flng Org | 0 | CompBsdNetEarnsFlngOrgInd |
| Comp Bsd Net Earns Rltd Orgs | 0 | CompBsdNetEarnsRltdOrgsInd |
| Any Non Fixed Payments | Yes (1) | AnyNonFixedPaymentsInd |
| Initial Contract Exception | 0 | InitialContractExceptionInd |
Rltd Org Officer Trst Key Empl RltdOrgOfficerTrstKeyEmplGrp (10 entries)
| TitleTitleTxt | Base Compensation Filing OrgBaseCompensationFilingOrgAmt | Compensation Based On Rltd OrgsCompensationBasedOnRltdOrgsAmt | Bonus Filing OrganizationBonusFilingOrganizationAmount | Bonus Related OrganizationsBonusRelatedOrganizationsAmt | Other Compensation Filing OrgOtherCompensationFilingOrgAmt | Other Compensation Rltd OrgsOtherCompensationRltdOrgsAmt | Deferred Compensation Flng OrgDeferredCompensationFlngOrgAmt | Deferred Comp Rltd OrgsDeferredCompRltdOrgsAmt | Nontaxable Benefits Filing OrgNontaxableBenefitsFilingOrgAmt | Nontaxable Benefits Rltd OrgsNontaxableBenefitsRltdOrgsAmt | Total Compensation Filing OrgTotalCompensationFilingOrgAmt | Total Compensation Rltd OrgsTotalCompensationRltdOrgsAmt | Comp Report Prior990 Filing OrgCompReportPrior990FilingOrgAmt | Comp Report Prior990 Rltd OrgsCompReportPrior990RltdOrgsAmt |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| JASON FAHRLANDER | ||||||||||||||
| DIRECTOR | $0 | $694,107 | $0 | $70,000 | $0 | $25,782 | $0 | $367,104 | $0 | $34,387 | $0 | $1,191,380 | $0 | $70,000 |
| ANDREW SONDERMAN MD | ||||||||||||||
| DIRECTOR STARTING FEB 2021 | $226,736 | $0 | $14,500 | $0 | $107,488 | $0 | $57,666 | $0 | $19,160 | $0 | $425,550 | $0 | $14,500 | $0 |
| JASON LANDIS | ||||||||||||||
| VP-FINANCE | $0 | $227,754 | $0 | $16,841 | $0 | $2,282 | $0 | $60,848 | $0 | $9,703 | $0 | $317,428 | $0 | $16,841 |
| THERESA ANDERSON RN | ||||||||||||||
| INTERIM CEO THROUGH AUG 2021 | $156,098 | $0 | $7,623 | $0 | $16,917 | $0 | $25,539 | $0 | $32,723 | $0 | $238,900 | $0 | $7,623 | $0 |
| CATHY BOGGS | ||||||||||||||
| EXECUTIVE DIRECTOR AND ADMINISTRATOR | $0 | $164,359 | $0 | $11,739 | $0 | $1,994 | $0 | $47,724 | $0 | $9,886 | $0 | $235,702 | $0 | $0 |
| ROBIN PARSON | ||||||||||||||
| DIRECTOR-BEHAVIORAL HEALTH | $125,077 | $0 | $6,198 | $0 | $1,789 | $0 | $24,286 | $0 | $9,850 | $0 | $167,200 | $0 | $6,198 | $0 |
| DANA PINKOWSKI | ||||||||||||||
| NURSE | $127,834 | $0 | $500 | $0 | $1,622 | $0 | $9,165 | $0 | $21,071 | $0 | $160,192 | $0 | $0 | $0 |
| JUDIE HUFF | ||||||||||||||
| PATIENT CARE COORDINATOR | $144,754 | $0 | $500 | $0 | $1,232 | $0 | $1,000 | $0 | $10,432 | $0 | $157,918 | $0 | $500 | $0 |
| RACHEL BOTKIN | ||||||||||||||
| APP | $120,503 | $0 | $3,500 | $0 | $1,793 | $0 | $7,930 | $0 | $20,660 | $0 | $154,386 | $0 | $0 | $0 |
| MARJORIE COMBELLICK | ||||||||||||||
| NURSE PRACTITIONER | $125,117 | $0 | $3,500 | $0 | $1,779 | $0 | $7,050 | $0 | $9,094 | $0 | $146,540 | $0 | $0 | $0 |
Supplemental Information Detail SupplementalInformationDetail (3 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| PART III - OTHER ADDITIONAL INFORMATION | PART I, LINE 3 - RELATED ORG METHODS USED FOR COMPENSATION EXPLANATION FAIRBANKS HOSPITAL, INC. ("FBH") CEO/EXECUTIVE DIRECTOR IS PAID BY COMMUNITY HEALTH NETWORK, INC. ("CHNW"), A RELATED 501(C)(3) ORGANIZATION. CHNW USES THE FOLLOWING IN DETERMINING THE CEO'S COMPENSATION: 1) COMPENSATION COMMITTEE, 2) INDEPENDENT COMPENSATION CONSULTANT, 3) COMPENSATION SURVEY OR STUDY, AND 4) APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE. |
| PART I, LINE 4B - SUPPLEMENTAL NONQUALIFIED RETIREMENT PLANS | COMMUNITY HEALTH NETWORK, INC. RESTORATION PLAN COMMUNITY HEALTH NETWORK, INC. ("COMMUNITY") ADOPTED THIS COMMUNITY HEALTH NETWORK RESTORATION PLAN ("PLAN") AS OF DECEMBER 1, 2017 TO PROVIDE A SUPPLEMENTAL INCOME FOR RETIREMENT UPON VESTING IN THE BENEFITS AS DESCRIBED IN THE PLAN DOCUMENT. FAIRBANKS HOSPITAL, INC. ("FBH") IS INCLUDED IN THE PLAN. THE PLAN IS DESIGNED UNDER CODE SECTION 457(F) AS A "TOP-HAT PLAN" (I.E. AN UNFUNDED DEFERRED COMPENSATION PLAN MAINTAINED FOR A SELECT GROUP OF MANAGEMENT OR HIGHLY COMPENSATED EMPLOYEES PURSUANT TO SECTIONS 201(2), 301(A)(3) AND 401(A)(1) OF THE EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974, AS AMENDED ("ERISA"). ELIGIBILITY: INDIVIDUALS WHO HAVE THE TITLE OF PRESIDENT, SENIOR VICE PRESIDENT OR EXECUTIVE VICE PRESIDENT AND WHOSE PLAN COMPENSATION FOR THE APPLICABLE PLAN YEAR EXCEEDS THE ANNUAL COMPENSATION LIMIT UNDER CODE SECTION 401(A) (17), AS ADJUSTED FROM TIME TO TIME. CONTRIBUTIONS: 1. MATCHING CONTRIBUTIONS: IF A PARTICIPANT RECEIVES THE MAXIMUM PERMISSIBLE MATCHING CONTRIBUTION UNDER THE COMMUNITY HEALTH NETWORK 401(K) RETIREMENT PLAN, THEY WILL RECEIVE A MATCHING CONTRIBUTION IN THE PLAN THAT IS EQUAL TO THEIR COMPENSATION THAT IS GREATER THAN THE 401(K) PLAN LIMIT MULTIPLIED BY THE MAXIMUM PERMITTED MATCHING CONTRIBUTION PERCENTAGE IN THE 401(K) PLAN FOR THAT YEAR. 2. NON-ELECTIVE CONTRIBUTIONS: IF A PARTICIPANT RECEIVES A NON-ELECTIVE CONTRIBUTION IN THE 401(K) PLAN, THEY WILL RECEIVE A NON-ELECTIVE CONTRIBUTION IN THE PLAN THAT IS EQUAL TO THEIR COMPENSATION THAT IS GREATER THAN THE 401(K) PLAN LIMIT MULTIPLIED BY THE NON-ELECTIVE CONTRIBUTION PERCENTAGE IN THE 401(K) PLAN FOR THAT YEAR. NOTE THAT NO NON-ELECTIVE CONTRIBUTIONS ARE CURRENTLY BEING MADE TO THE 401(K) PLAN. CONTRIBUTIONS WILL BE CREDITED TO A PARTICIPANT'S ACCOUNT AS SOON AS ADMINISTRATIVELY FEASIBLE FOLLOWING THE END OF THE PLAN YEAR TO WHICH THE CONTRIBUTIONS RELATE. VESTING: A PARTICIPANT WILL BE 100% VESTED IN HIS ACCOUNT UPON THE EARLIEST TO OCCUR OF THE FOLLOWING: 1. ATTAINMENT OF AGE 65 PRIOR TO SEPARATION FROM SERVICE 2. DISABILITY 3. INVOLUNTARY SEPARATION FROM SERVICE FOR A REASON OTHER THAN FOR CAUSE 4. SEPARATION FROM SERVICE FOR GOOD REASON 5. A NONCOMPETITIVE PARTICIPANT'S COMPLIANCE WITH ALL TERMS OF A NONCOMPETING AGREEMENT, OR 6. DEATH FORFEITURES: IF ACCOUNT IS NOT VESTED AS DESCRIBED ABOVE, THE ACCOUNT WILL BE COMPLETELY FORFEITED. AMOUNTS FORFEITED DURING A PLAN YEAR REMAIN A GENERAL ASSET OF COMMUNITY. |
| PART I, LINE 7 - NON-FIXED PAYMENTS PROVIDED | SENIOR LEADERSHIP INCENTIVE PROGRAM FAIRBANKS HOSPITAL, INC., PARTICIPATES IN THE NETWORK'S SENIOR LEADERSHIP INCENTIVE PROGRAM. CERTAIN INDIVIDUALS OF THE LEADERSHIP TEAM PARTICIPATE IN THIS PROGRAM. THE PROGRAM WAS ADOPTED BY THE EXECUTIVE COMPENSATION COMMITTEE, AND IS INTENDED TO INFLUENCE OUTSTANDING PERFORMANCE BY THE SENIOR LEADERS, AS MEASURED AGAINST ORGANIZATIONAL PERFORMANCE. THE PROGRAM IS REVIEWED ANNUALLY BY THE EXECUTIVE COMPENSATION COMMITTEE, WHICH IS COMPOSED ENTIRELY OF INDEPENDENT COMMUNITY MEMBERS. THE INCENTIVE COMPENSATION THAT IS AWARDED IS INCLUDED IN TOTAL COMPENSATION TO THE EXECUTIVE. THE TOTAL COMPENSATION (INCLUDING ANY PAYMENTS UNDER THE PROGRAM) IS SUBJECT TO THE REVIEW AND APPROVAL OF THE EXECUTIVE COMPENSATION COMMITTEE AND INDEPENDENT COMPENSATION CONSULTANT, IN CONSIDERATION OF CODE SECTION 4958 (AND THE CORRESPONDING TREASURY REGULATIONS) TO ENSURE THAT IT REFLECTS ARM'S LENGTH, FAIR MARKET TERMS. |
Schedule O IRS990ScheduleO
Supplemental Information Detail SupplementalInformationDetail (13 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| FORM 990, PART V, LINE 1A - BOX 3 OF FORM 1096 | FORM 1099S WERE PROCESSED UNDER THE NAME AND FEDERAL IDENTIFICATION NUMBER OF COMMUNITY HEALTH NETWORK, INC. |
| FORM 990, PART VI, SECTION A, LINE 2 | RELATED PARTY INFORMATION AMONG OFFICERS JASON FAHRLANDER SERVED AS AN OFFICER OF COMMUNITY HEALTH NETWORK, INC. ("CHNW"). JASON FAHRLANDER, JASON LANDIS, AND CATHY BOGGS RECEIVED COMPENSATION FROM CHNW. |
| FORM 990, PART VI, SECTION A, LINE 3 | MANAGEMENT DELEGATED THE BYLAWS WERE AMENDED AS OF NOVEMBER 30, 2019 AND THE FOLLOWING ACTIONS NOW REQUIRE, IN ADDITION TO THE APPROVAL OR RECOMMENDATION OF THE BOARD, WRITTEN APPROVAL FROM COMMUNITY HEALTH NETWORK, INC. ("CHNW"), THE SOLE MEMBER OF FAIRBANKS: A) AMENDMENT OF ORGANIZATIONAL DOCUMENTS, B) UNBUDGETED INDEBTEDNESS - THE INCURRENCE OF ANY UNBUDGETED LOANS OR OTHER INDEBTEDNESS IN AN AGGREGRATE AMOUNT GREATER THAN $500,000, C) SIGNIFICANT CHANGES - THE FORMATION OF LEGAL ENTITIES, THE SALE, TRANSFER OR SUBSTANTIAL CHANGE IN USE OF ALL OR SUBSTANTIALLY OF ALL THE ASSETS OF THE CORPORATION, OR THE DIVESTURE, DISSOLUTION, CLOSURE, MERGER, CONSOLIDATION OR REORGANIZATION OF THE CORPORATION, D) ASSET ACQUISITIONS AND SALES ABOVE $100,000, E) DISPOSITION OF ASSETS ON DISSOLUTION, F) CAPITAL AND OPERATING BUDGETS, PLANS, OR FORECASTS, G) AUDITORS - THE SELECTION, EVALUATION AND TERMINATION OF THE INDEPENDENT AUDITING FIRM FOR THE CORPORATION, H) CERTAIN COMPENSATION FOR EMPLOYED PHYSICIANS, THE CORPORATION'S PRESIDENT, AND SENIOR ADMINISTRATORS OR LEADERS OF THE CORPORATION OR INDEPENDENT PHYSICIANS PROVIDING SERVICES TO THE CORPORATION, I) CAPITAL IMPROVEMENTS GREATER THAN THE BUDGETED AMOUNT BY $100,000 PER FISCAL YEAR IN THE AGGREGATE, J) STRATEGIC PLANS, K) PRESIDENT'S EMPLOYMENT, AND L) THE LINES OF BUSINESS - COMMENCEMENT OR DISCONTINUATION OF ANY LINE OF BUSINESS OR HEALTHCARE SERVICES TO BE PROVIDED AT THE CORPORATION'S FACILITIES. |
| FORM 990, PART VI, SECTION A, LINE 6 | CLASSES OF MEMBERS OR STOCKHOLDERS EFFECTIVE NOVEMBER 30, 2019, COMMUNITY HEALTH NETWORK, INC. ("CHNW") BECAME THE SOLE MEMBER OF FAIRBANKS HOSPITAL, INC. |
| FORM 990, PART VI, SECTION A, LINE 7A | ELECTION OF MEMBERS AND THEIR RIGHTS CHNW, THE SOLE MEMBER OF FAIRBANKS, DIRECTLY APPOINTS AND REMOVES A MAJORITY OF THE BOARD OF DIRECTORS. THE BOARD SHALL CONSIST OF NO MORE THAN 16 DIRECTORS. THE DIRECTORS SHALL SERVE STAGGERED 3 YEAR FULL CONSECUTIVE TERMS AND SHALL COMPLY WITH ALL REQUIREMENTS IMPOSED BY ANY APPLICABLE HEALTH CARE REGULATORY OR ACCREDITING BODY TO WHICH THE CORPORATION IS SUBJECT. IN ADDITION, ALL DIRECTORS SHALL BE SUBJECT TO ALL APPLICABLE SELF-EVALUATION AND QUALIFICATION REQUIREMENTS OF THE MEMBER. ANY VACANCIES AMONG THE DIRECTORS SHALL BE FILLED BY THE MEMBER. THE MEMBER MAY ALSO REMOVE, WITH OR WITHOUT CAUSE, ANY DIRECTOR. |
| FORM 990, PART VI, SECTION A, LINE 7B | DECISIONS SUBJECT TO APPROVAL OF MEMBERS IN ADDITION TO THE APPROVAL OR RECOMMENDATION OF THE BOARD, THE FOLLOWING REQUIRE WRITTEN APPROVAL FROM CHNW, THE SOLE MEMBER OF FAIRBANKS: A) AMENDMENT OF ORGANIZATIONAL DOCUMENTS, B) UNBUDGETED INDEBTEDNESS - THE INCURRENCE OF ANY UNBUDGETED LOANS OR OTHER INDEBTEDNESS IN AN AGGREGRATE AMOUNT GREATER THAN $500,000, C) SIGNIFICANT CHANGES - THE FORMATION OF LEGAL ENTITIES, THE SALE, TRANSFER OR SUBSTANTIAL CHANGE IN USE OF ALL OR SUBSTANTIALLY OF ALL THE ASSETS OF THE CORPORATION, OR THE DIVESTURE, DISSOLUTION, CLOSURE, MERGER, CONSOLIDATION OR REORGANIZATION OF THE CORPORATION, D) ASSET ACQUISITIONS AND SALES ABOVE $100,000, E) DISPOSITION OF ASSETS ON DISSOLUTION, F) CAPITAL AND OPERATING BUDGETS, PLANS, OR FORECASTS, G) AUDITORS - THE SELECTION, EVALUATION AND TERMINATION OF THE INDEPENDENT AUDITING FIRM FOR THE CORPORATION, H) CERTAIN COMPENSATION FOR EMPLOYED PHYSICIANS, THE CORPORATION'S PRESIDENT, AND SENIOR ADMINISTRATORS OR LEADERS OF THE CORPORATION OR INDEPENDENT PHYSICIANS PROVIDING SERVICES TO THE CORPORATION, I) CAPITAL IMPROVEMENTS GREATER THAN THE BUDGETED AMOUNT BY $100,000 PER FISCAL YEAR IN THE AGGREGATE, J) STRATEGIC PLANS, K) PRESIDENT'S EMPLOYMENT, AND L) THE LINES OF BUSINESS - COMMENCEMENT OR DISCONTINUATION OF ANY LINE OF BUSINESS OR HEALTHCARE SERVICES TO BE PROVIDED AT THE CORPORATION'S FACILITIES. |
| FORM 990, PART VI, SECTION B, LINE 11B | ORGANIZATION'S PROCESS TO REVIEW FORM 990 CHNW'S BOARD OF DIRECTORS HAS DELEGATED AUTHORITY FOR THE REVIEW OF FAIRBANKS' FORM 990 TO TWO COMMITTEES COMPOSED OF INDEPENDENT OUTSIDE DIRECTORS, INCLUDING SPECIFICALLY THE PREPARATION AND REVIEW OF FBH'S FORM 990: A) THE NETWORK EXECUTIVE COMPENSATION COMMITTEE REVIEWED THE COMPENSATION ASPECTS OF FAIRBANKS' FORM 990, AND B) THE NETWORK FINANCE COMMITTEE REVIEWED THE REMAINDER OF THE FAIRBANKS' FORM 990. IN ADDITION, FAIRBANKS' OUTSIDE ACCOUNTING FIRM AND LAW FIRM REVIEWED THE FORM 990 PRIOR TO FILING. FAIRBANKS AND CHNW UTILIZED THIS PROCESS TO ENSURE THAT FAIRBANKS' FORM 990 RECEIVED SUBSTANTIVE REVIEW BY DIRECTORS AND PROFESSIONALS WITH SPECIFIC KNOWLEDGE OF FAIRBANKS' ACTIVITIES AND EXTENSIVE FINANCIAL, ACCOUNTING, AND TAX EXPERTISE. |
| FORM 990, PART VI, SECTION B, LINE 12C | ENFORCEMENT OF CONFLICTS POLICY FAIRBANKS HAS DELEGATED AUTHORITY FOR AUDIT AND COMPLIANCE TO CHNW. THE CONFLICT OF INTEREST POLICY REQUIRES DIRECTORS, OFFICERS, AND KEY EMPLOYEES TO SUBMIT AN ANNUAL CONFLICT OF INTEREST DISCLOSURE. THE ANNUAL DISCLOSURE REQUIRES DIRECTORS, OFFICERS, AND KEY EMPLOYEES TO DISCLOSE, IN WRITING, ANY KNOWN FINANCIAL INTEREST THAT THE INDIVIDUAL (TOGETHER WITH FAMILY MEMBERS) HAS IN ANY BUSINESS ENTITY THAT TRANSACTS BUSINESS WITH FAIRBANKS. IN ADDITION, DIRECTORS, OFFICERS, AND KEY EMPLOYEES ARE REQUIRED TO IMMEDIATELY DISCLOSE ANY POSSIBLE CONFLICT OF INTEREST THAT ARISES MID-YEAR IN RELATION TO A PROPOSED TRANSACTION. THE CONFLICT OF INTEREST POLICY REQUIRES THAT ANY INDIVIDUAL WITH A CONFLICT BE RECUSED FROM THE DECISION MAKING PROCESS, THAT INDEPENDENT DIRECTORS OR COMMITTEE MEMBERS DETERMINE THAT THE PROPOSED TRANSACTION IS IN THE BEST INTEREST OF FAIRBANKS, AND THE TRANSACTION MUST BE APPROVED BY A VOTE OF INDEPENDENT DIRECTORS OR COMMITTEE MEMBERS WITHOUT THE PARTICIPATION OF ANY INTERESTED INDIVIDUAL. THE ANNUAL CONFLICT DISCLOSURE STATEMENTS ARE SUBMITTED TO, AND REVIEWED BY, CHNW'S AUDIT COMMITTEE, COMPOSED OF INDEPENDENT DIRECTORS. IN ADDITION, THE EXECUTIVE STAFF AND GENERAL COUNSEL OF THE NETWORK ARE RESPONSIBLE FOR MONITORING ANY POSSIBLE CONFLICT TRANSACTIONS THAT ARISE AND MANAGING THEM TO ENSURE THAT ALL TRANSACTIONS REPRESENT ARMS LENGTH, FAIR MARKET VALUE TERMS FOR THE BENEFIT OF FAIRBANKS. |
| FORM 990, PART VI, SECTION B, LINE 15 | COMPENSATION PROCESS FOR TOP OFFICIAL AS A MEMBER OF THE NETWORK, FAIRBANKS IS SUBJECT TO THE EXECUTIVE COMPENSATION PRACTICES AND PROCEDURES OF CHNW, THE NETWORK PARENT. CHNW HAS ADOPTED AN EXECUTIVE COMPENSATION AND INTERMEDIATE SANCTIONS POLICY THAT APPLIES TO FAIRBANKS. THE PURPOSE OF THE POLICY IS TO ENSURE THAT FAIRBANKS' COMPENSATION ARRANGEMENTS WITH RELATED PARTIES ARE EVALUATED AND ENTERED AT ARMS LENGTH AND THAT ANY COMPENSATION THAT IS PAID TO A RELATED PARTY IS REASONABLE AND REFLECTS FAIR MARKET VALUE. THIS POLICY ENCOURAGES THE APPLICATION OF THE REBUTTABLE PRESUMPTION STANDARD OF CODE SECTION 4958 AND THE RELATED TREASURY REGULATIONS BY: A) EXCLUDING ANY INTERESTED PARTY FROM THE DECISION MAKING PROCESS, B) REQUIRING DISINTERESTED BOARD OR COMMITTEE MEMBERS TO OBTAIN AND RELY UPON COMPARABILITY DATA WHEN SETTING THE PROPOSED COMPENSATION TERMS, C) REQUIRING APPROVAL OF THE TRANSACTION IN ADVANCE BY DISINTERESTED DIRECTORS OR COMMITTEE MEMBERS, AND D) REQUIRING CONTEMPORANEOUS DOCUMENTATION (I.E. MINUTES) REFLECTING THE DECISION AND THE PROCESS BY WHICH IT WAS MADE. CHNW ALSO DELEGATED AUTHORITY REGARDING FAIRBANKS' EXECUTIVE COMPENSATION TO A) THE NETWORK EXECUTIVE COMPENSATION COMMITTEE, COMPOSED OF INDEPENDENT OUTSIDE DIRECTORS, WHICH IS RESPONSIBLE FOR APPLYING THE TERMS AND PROCESS OF THE EXECUTIVE COMPENSATION AND INTERMEDIATE SANCTIONS POLICY AS OUTLINED ABOVE, AND B) THE NETWORK VICE PRESIDENT OF HUMAN RESOURCES WHO IS RESPONSIBLE FOR OBTAINING COMPARATIVE SALARY MARKET DATA FOR THE CHIEF EXECUTIVE OFFICER, OFFICERS, AND KEY EMPLOYEES, ENGAGING AN INDEPENDENT COMPENSATION CONSULTANT TO PROVIDE REASONABLE COMPENSATION ANALYSIS AND/OR CONFIRM THE REASONABLENESS OF COMPENSATION, AND PROVIDING STAFF SUPPORT TO THE NETWORK EXECUTIVE COMPENSATION COMMITTEE. DURING 2021, THE NETWORK EXECUTIVE COMPENSATION COMMITTEE FOLLOWED THIS PROCESS FOR ALL SENIOR EXECUTIVE LEADERS. FORM 990, PART VI, LINE 15B - COMPENSATION PROCESS FOR OFFICERS SEE LINE 15A ABOVE |
| FORM 990, PART VI, SECTION C, LINE 19 | GOVERNING DOCUMENTS DISCLOSURE EXPLANATION A) THE ARTICLES OF INCORPORATION AND BUSINESS ENTITY REPORT ARE ON FILE WITH THE INDIANA SECRETARY OF STATE AND ARE AVAILABLE TO THE PUBLIC UPON REQUEST TO THE INDIANA SECRETARY OF STATE OR FREE OF CHARGE ON THE SECRETARY OF STATE'S WEBSITE. B) AS A MEMBER OF THE NETWORK, FAIRBANKS HAS ADOPTED THE NETWORK CONFLICT OF INTEREST POLICY. WHILE THIS POLICY IS NOT AVAILABLE TO THE PUBLIC, THE NETWORK'S DEFINITION OF CONFLICT OF INTEREST AND HOW TO REPORT SUCH AN INCIDENT IS DESCRIBED IN THE NETWORK RESPONSBILITY AND COMPLIANCE PROGRAM ("NRCP") MANUAL WHICH IS POSTED ON THE NETWORK'S WEBSITE, ECOMMUNITY.COM. THIS MANUAL IS AVAILABLE FOR THE PUBLIC TO REVIEW. C) FAIRBANKS DOES NOT HAVE INDIVIDUALLY AUDITED FINANCIAL STATEMENTS. ITS FINANCIAL RESULTS ARE INCLUDED IN THE CONSOLIDATED FINANCIAL STATEMENTS OF CHNW AND AFFILIATES. AS SUCH, THERE ARE NO INDIVIDUAL FINANCIAL STATEMENTS TO POST. FAIRBANKS DOES FILE THE 990 TAX RETURN ON AN ANNUAL BASIS WHICH IS AVAILABLE UPON REQUEST AND/OR AVAILABLE ON A DELAYED BASIS ON GUIDESTAR.ORG. D) COMMUNITY HEALTH NETWORK, INC. AND AFFILIATES PROVIDE ANY DOCUMENT OPEN TO PUBLIC INSPECTION UPON REQUEST. |
| FORM 990, PART VII, SECTION B - INDEPENDENT CONTRACTOR DISCLOSURE | COMPENSATION TO BLAKLEY'S CORPORATION, INC. INCLUDES MATERIAL COSTS. |
| FORM 990, PART IX, LINE 11G | PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 641,655. MANAGEMENT AND GENERAL EXPENSES 4,531,207. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 5,172,862. |
| FORM 990, PART XI, LINE 9: | TRANSFER OF FUNDS TO COMMUNITY HEALTH NETWORK FOUNDATION -79,313. |
Schedule R IRS990ScheduleR
Id Related Tax Exempt Org IdRelatedTaxExemptOrgGrp (9 entries)
| Address Line1USAddress/AddressLine1Txt | CityUSAddress/CityNm | State AbbreviationUSAddress/StateAbbreviationCd | ZIPUSAddress/ZIPCd | EINEIN | Primary ActivitiesPrimaryActivitiesTxt | Legal Domicile StateLegalDomicileStateCd | Exempt Code SectionExemptCodeSectionTxt | Public Charity StatusPublicCharityStatusTxt | Direct Controlling NADirectControllingNACd | Controlled OrganizationControlledOrganizationInd | Business Name Line1DirectControllingEntityName/BusinessNameLine1Txt |
|---|---|---|---|---|---|---|---|---|---|---|---|
| COMMUNITY HEALTH NETWORK INC | |||||||||||
| 7330 SHADELAND STATION SUITE 200 | INDIANAPOLIS | IN | 46256 | 350983617 | HOSPITAL | IN | 501(C)(3) | LINE 3 | N/A | 0 | |
| COMMUNITY HEALTH NETWORK FOUNDATION | |||||||||||
| 7330 SHADELAND STATION SUITE 100 | INDIANAPOLIS | IN | 46256 | 510181688 | SUPPORT | IN | 501(C)(3) | LINE 12B, II | Yes (1) | CHNW | |
| COMMUNITY HOME HEALTH SERVICES INC | |||||||||||
| 9894 EAST 121ST STREET | FISHERS | IN | 46037 | 350953467 | HEALTH CARE | IN | 501(C)(3) | LINE 10 | Yes (1) | CHNW | |
| COMM HOSP OF ANDERSON & MADISON CTY | |||||||||||
| 1515 NORTH MADISON AVENUE | ANDERSON | IN | 46011 | 351069822 | HOSPITAL | IN | 501(C)(3) | LINE 3 | Yes (1) | CHNW | |
| COMMUNITY HOSP ANDERSON FDN INC | |||||||||||
| 1515 NORTH MADISON AVENUE | ANDERSON | IN | 46011 | 861053152 | SUPPORT | IN | 501(C)(3) | LINE 12A, I | Yes (1) | CHA | |
| COMMUNITY HOSPITAL SOUTH INC | |||||||||||
| 1402 E COUNTY LINE ROAD SOUTH | INDIANAPOLIS | IN | 46227 | 351088640 | HOSPITAL | IN | 501(C)(3) | LINE 3 | Yes (1) | CHNW | |
| COMMUNITY HOWARD REGIONAL HEALTH | |||||||||||
| 3500 S LAFOUNTAIN STREET | KOKOMO | IN | 46902 | 351865344 | HOSPITAL | IN | 501(C)(3) | LINE 3 | Yes (1) | CHNW | |
| COMM HOWARD REGIONAL HEALTH FDN | |||||||||||
| PO BOX 9011 | KOKOMO | IN | 46904 | 237309596 | SUPPORT | IN | 501(C)(3) | LINE 7 | N/A | 0 | |
| COMMUNITY PHYSICIANS OF IN INC | |||||||||||
| 7240 SHADELAND STATION SUITE 200 | INDIANAPOLIS | IN | 46256 | 205392766 | PHYSICIAN SERVICES | IN | 501(C)(3) | LINE 10 | Yes (1) | CHNW | |
Id Related Org Txbl Partnership IdRelatedOrgTxblPartnershipGrp (20 entries)
| Address Line1USAddress/AddressLine1Txt | CityUSAddress/CityNm | State AbbreviationUSAddress/StateAbbreviationCd | ZIPUSAddress/ZIPCd | EINEIN | Primary ActivitiesPrimaryActivitiesTxt | Legal Domicile StateLegalDomicileStateCd | Direct Controlling NADirectControllingNACd | Disproportionate AllocationsDisproportionateAllocationsInd | General Or Managing PartnerGeneralOrManagingPartnerInd |
|---|---|---|---|---|---|---|---|---|---|
| CHNJMH VENTURES LLC | |||||||||
| 6626 E 75TH STREET SUITE 200 | INDIANAPOLIS | IN | 46250 | 462356266 | DIAG/REHAB | IN | N/A | 0 | 0 |
| COMMUNITY ENDOSCOPY CENTER LLC | |||||||||
| 1601 N MADISON AVENUE SUITE 300 | ANDERSON | IN | 46011 | 611464136 | HEALTH CARE | IN | N/A | 0 | 0 |
| COMMUNITY HEALTH AT HOME LLC | |||||||||
| 1700 EDISON DRIVE | MILFORD | OH | 451502729 | 833536760 | HOME CARE | IN | N/A | 0 | 0 |
| COMMUNITY HEALTH NETWORK REHAB HOSP LLC | |||||||||
| 680 S FOURTH STREET | LOUISVILLE | KY | 40202 | 453414249 | REHAB | IN | N/A | 0 | 0 |
| COMMUNITY HEALTH NTWRK REHAB HOSP SOUTH LLC | |||||||||
| 680 S FOURTH STREET | LOUISVILLE | KY | 40202 | 821385366 | REHAB | IN | N/A | 0 | 0 |
| COMMUNITY HEALTH NTWRK REHAB HOSP WEST LLC | |||||||||
| 330 SEVEN SPRINGS WAY | BRENTWOOD | TN | 37027 | 845110509 | REHAB | IN | N/A | 0 | 0 |
| EAST CAMPUS SURGERY CENTER LLC | |||||||||
| 6626 E 75TH STREET SUITE 200 | INDIANAPOLIS | IN | 46250 | 352028517 | SURGERY | IN | N/A | 0 | 0 |
| HAMILTON SURGERY CENTER LLC | |||||||||
| 6626 E 75TH STREET SUITE 200 | INDIANAPOLIS | IN | 46250 | 352061413 | SURGERY | IN | N/A | 0 | 0 |
| HEALTHBOX CHICAGO II LLC | |||||||||
| 33 WEST MONROE STREET SUITE 1700 | CHICAGO | IL | 60603 | 463871950 | INVESTMENT | IL | N/A | 0 | 0 |
| HOWARD COMMUNITY SURGERY CTR LLC | |||||||||
| 3500 S LAFOUNTAIN STREET | KOKOMO | IN | 46902 | 352118748 | SURGERY | IN | N/A | 0 | 0 |
| INDIANAPOLIS ENDOSCOPY CENTER LLP | |||||||||
| 8315 E 56TH STREET | INDIANAPOLIS | IN | 46216 | 352010874 | HEALTH CARE | IN | N/A | 0 | 0 |
| MICHIGAN SURGERY INVESTMENT LLC | |||||||||
| 6626 E 75TH STREET SUITE 200 | INDIANAPOLIS | IN | 46250 | 320147008 | SURGERY CENTERS | IN | N/A | 0 | 0 |
| NORTH CAMPUS OFFICE ASSOCIATES LP | |||||||||
| 6626 E 75TH STREET SUITE 200 | INDIANAPOLIS | IN | 46250 | 351808625 | RENTAL PROPERTY | IN | N/A | 0 | 0 |
| NORTH CAMPUS SURGERY CENTER LLC | |||||||||
| 6626 E 75TH STREET SUITE 200 | INDIANAPOLIS | IN | 46250 | 352147088 | SURGERY | IN | N/A | 0 | 0 |
| NORTHPOINT PEDIATRICS LLC | |||||||||
| 8101 CLEARVISTA PARKWAY SUITE 185 | INDIANAPOLIS | IN | 46256 | 351960566 | HEALTH CARE | IN | N/A | 0 | 0 |
| NORTHWEST SURGERY CENTER LLC | |||||||||
| 6626 E 75TH STREET SUITE 200 | INDIANAPOLIS | IN | 46250 | 208754071 | SURGERY | IN | N/A | 0 | 0 |
| PILLARS HOUSING LP | |||||||||
| 3500 S LAFOUNTAIN STREET | KOKOMO | IN | 46902 | 161652671 | HOUSING | IN | N/A | 0 | 0 |
| PRIMARIA HEALTH LLC | |||||||||
| 9365 COUNSELORS ROW SUITE 210 | INDIANAPOLIS | IN | 46240 | 474728937 | HEALTH CARE | IN | N/A | 0 | 0 |
| SCP INDIANAPOLIS LLC | |||||||||
| 7430 SHADELAND AVENUE SUITE 100 | INDIANAPOLIS | IN | 46250 | 460639908 | HEALTH CARE | IN | N/A | 0 | 0 |
| SOUTH CAMPUS SURGERY CENTER LLC | |||||||||
| 1550 EAST COUNTY LINE ROAD | INDIANAPOLIS | IN | 46227 | 352038072 | SURGERY | IN | N/A | 0 | 0 |
Id Related Org Txbl Corp Tr IdRelatedOrgTxblCorpTrGrp (5 entries)
| Address Line1ForeignAddress/AddressLine1Txt | CityForeignAddress/CityNm | CountryForeignAddress/CountryCd | EINEIN | Primary ActivitiesPrimaryActivitiesTxt | Legal Domicile Foreign CountryLegalDomicileForeignCountryCd | Direct Controlling NADirectControllingNACd | Entity TypeEntityTypeTxt | Controlled OrganizationControlledOrganizationInd | Address Line1USAddress/AddressLine1Txt | CityUSAddress/CityNm | State AbbreviationUSAddress/StateAbbreviationCd | ZIPUSAddress/ZIPCd | Legal Domicile StateLegalDomicileStateCd |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| CHN ASSURANCE COMPANY LTD | |||||||||||||
| PO BOX 1051GT | GRAND CAYMAN | CJ | 980418913 | SELF INSURANCE | CJ | N/A | C | 0 | |||||
| PILLARS COMMUNITY HOUSING INC | |||||||||||||
| 161652666 | HOUSING | N/A | C | 0 | 3500 S LAFOUNTAIN STREET | KOKOMO | IN | 46902 | IN | ||||
| VISIONARY ENTERPRISES INC | |||||||||||||
| 351538433 | MANAGEMENT SERVICES | N/A | C | 0 | 6626 EAST 75TH STREET SUITE 200 | INDIANAPOLIS | IN | 46250 | IN | ||||
| VEI MICHIGAN INC | |||||||||||||
| 300097377 | MANAGEMENT SERVICES | N/A | C | 0 | 940 N MAIN STREET | ANN HARBOR | MI | 48104 | MI | ||||
| WESTVIEW DELIVERY SYSTEM INC | |||||||||||||
| 351910292 | MANAGEMENT SERVICES | N/A | C | 0 | 3630 GUION ROAD | INDIANAPOLIS | IN | 46222 | IN | ||||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Receipt Of Int Annts Rnts Rylts | 0 | ReceiptOfIntAnntsRntsRyltsInd |
| Gift Grnt Or Cap Contri To Oth Org | 0 | GiftGrntOrCapContriToOthOrgInd |
| Gift Grnt Cap Contri From Oth Org | Yes (1) | GiftGrntCapContriFromOthOrgInd |
| Loans Or Guarantees To Other Org | 0 | LoansOrGuaranteesToOtherOrgInd |
| Loans Or Guarantees From Oth Org | 0 | LoansOrGuaranteesFromOthOrgInd |
| Div Related Organization | 0 | DivRelatedOrganizationInd |
| Asset Sale To Other Org | 0 | AssetSaleToOtherOrgInd |
| Asset Purchase From Other Org | 0 | AssetPurchaseFromOtherOrgInd |
| Asset Exchange | 0 | AssetExchangeInd |
| Rental Of Facilities To Oth Org | 0 | RentalOfFacilitiesToOthOrgInd |
| Rental Of Fclts From Oth Org | 0 | RentalOfFcltsFromOthOrgInd |
| Perform Of Services For Oth Org | 0 | PerformOfServicesForOthOrgInd |
| Perform Of Services By Other Org | Yes (1) | PerformOfServicesByOtherOrgInd |
| Sharing Of Facilities | Yes (1) | SharingOfFacilitiesInd |
| Paid Employees Sharing | 0 | PaidEmployeesSharingInd |
| Reimbursement Paid To Other Org | Yes (1) | ReimbursementPaidToOtherOrgInd |
| Reimbursement Paid By Other Org | Yes (1) | ReimbursementPaidByOtherOrgInd |
| Transfer To Other Org | Yes (1) | TransferToOtherOrgInd |
| Transfer From Other Org | Yes (1) | TransferFromOtherOrgInd |
Transactions Related Org TransactionsRelatedOrgGrp (2 entries)
| Transaction TypeTransactionTypeTxt | InvolvedInvolvedAmt | Method Of Amount DeterminationMethodOfAmountDeterminationTxt |
|---|---|---|
| COMMUNITY HEALTH NETWORK FOUNDATION INC | ||
| R | $728,812 | BOOK VALUE |
| COMMUNITY HEALTH NETWORK FOUNDATION INC | ||
| C | $728,862 | BOOK VALUE |