2021-01-28T14:55:09-06:00 2020-06-30 390758449 WIPFLI LLP 1 MARKET SQUARE AUGUSTA ME 043304637 990 2019-07-01 010284446 REDINGTON-FAIRVIEW GENERAL HOSPITAL REDI 2074745121 PO BOX 468 SKOWHEGAN ME 049760468 ELMER DOUCETTE CFO 2074745121 2021-01-28 1 BOB DUBE CPA P01231018 2076224766 2021-01-25 2019 2022-09-23 18:48:47Z RICHARD D WILLETT PO BOX 468 SKOWHEGAN ME 049760468 117528504 0 X WWW.RFGH.NET X 1969 ME 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 SERVICES. 9 6 868 38 0 0 2107743 1986563 106924786 104628846 1131439 2293267 3955156 8619828 114119124 117528504 0 0 0 0 62345863 62906272 0 0 0 46964812 49118330 109310675 112024602 4808449 5503902 118112881 136219869 38100115 55665927 80012766 80553942 X SEE SCHEDULE O 0 0 54937531 82267110 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 2020, RFGH HAD 23,494 EMERGENCY DEPARTMENT VISITS AND 3,399 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. IN TOTAL, THESE SERVICES TREATED APPROXIMATELY 48,188 PATIENTS. 26701455 12141474 RFGH OPERATES A NUMBER OF PHYSICIAN OFFICES IN ORDER TO BETTER SERVE THE RESIDENTS OF SOMERSET COUNTY. DURING FISCAL 2020, THESE PHYSICIAN SPECIALTIES INCLUDED INTERNAL MEDICINE, ENDOCRINOLOGY, GENERAL SURGERY, ORTHOPEDICS, PEDIATRICS, FAMILY MEDICINE, OBSTETRICS, GASTROENTEROLOGY, NEUROLOGY, AND UROLOGY. DURING FISCAL 2020, THESE PHYSICIAN SPECIALTIES SERVED 14,949 PATIENTS WHO TOTALLED 57,126 VISITS AT THESE OFFICES. 15455745 10220262 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 2020, RFGH PROVIDED INPATIENT SERVICES TO 1,178 PATIENTS WHO STAYED 3,923 PATIENT DAYS. MEDICARE AND MEDICAID PATIENTS REPRESENTED 69% OF RFGH'S INPATIENTS. 1297940 1099633 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. 1297940 1099633 98392671 1 1 0 1 0 0 0 0 0 0 1 0 0 0 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 65 0 1 868 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 CHRISTOPHER PERKINS PRESIDENT 2.00 X X 0 0 0 L JOSEPH CLARK VICE PRESIDENT 2.00 X X 0 0 0 JEFFREY LLOYD TREASURER 2.00 X X 0 0 0 JEFFREY MCGOWN DIRECTOR 2.00 X 0 0 0 MICHAEL CURRAN MD DIRECTOR 50.00 X 490744 0 3671 WILLIAM LANEY DIRECTOR 2.00 X 0 0 0 MICHAEL LAMBKE MD DIRECTOR 50.00 X 216465 0 2516 JOHN WITHERSPOON DIRECTOR 2.00 X 0 0 0 GINA GOMEZ MD DIRECTOR 50.00 X 312882 0 5909 RICHARD D WILLETT CEO/SECRETARY 50.00 X 387877 0 9800 DANA C KEMPTON ASSOCIATE DIRECTOR 50.00 X 296301 0 8628 ELMER DOUCETTE CFO 50.00 X 243395 0 1646 TIRUNELLAI R SHANKAR MD SURGEON 50.00 X 609887 0 2903 AMIR BAIG MD ANESTHESIOLOGIST 50.00 X 399710 0 3682 JOHN COMIS MD ER PHYSICIAN 50.00 X 430589 0 4294 NANCY FLEMING MD ER PHYSICIAN 50.00 X 340698 0 1341 GANNA CHUGAY MD ANESTHESIOLOGIST 50.00 X 331362 0 2750 4059910 0 47140 80 0 1 0 WEATHERBY LOCUM PO BOX 972633 DALLAS TX 75397 CLINICAL STAFFING 1623404 FOCUSONE SOLUTIONS LLC PO BOX 310861 DESMOINES IA 503310861 CLINICAL STAFFING 971471 VISTA STAFFING SOLUTIONS 275 EAST 200 SOUTH SALT LAKE CITY UT 84111 CLINICAL STAFFING 880045 LANGFORD & LOW CONSTRUCTION PO BOX 662 PORTLAND ME 04104 CONSTRUCTION 702638 COMPHEALTH 7259 S BINGHAM JCT BLVD MIDVALE UT 84047 CLINICAL STAFFING 527572 23 852447 1134116 1986563 NET PATIENT REVENUE 622110 104628846 104628846 104628846 2293267 2293267 CARES ACT PROVIDER RELIEF FUNDS 4493000 4493000 OTHER MISCELLANEOUS 3840452 3840452 CAFETERIA 286376 286376 8619828 117528504 112962298 0 2579643 1858927 975290 883637 44039002 40445958 3593044 1731391 1383925 347466 12294396 9827084 2467312 2982556 2383999 598557 20084 20084 319387 319387 9986 9986 424159 424159 9856947 8693016 1163931 97726 97726 6115087 5016131 1098956 2670343 2187349 482994 1318856 1104453 214403 68127 61340 6787 204380 184020 20360 878532 691989 186543 3691669 2907800 783869 662021 504635 157386 BAD DEBT EXPENSE 11575030 11575030 PHARMACEUTICALS 7114039 7114039 HOSPITAL PROVIDER TAX 2029578 2029578 EQUIPMENT & MAINTENANCE 1053028 976082 76946 1009351 330953 678398 112024602 98392671 13631931 0 2825410 27135294 3368764 8636306 14764286 8796052 375747 297966 1583871 1900494 248554 247780 93201479 67644356 25929519 25557123 68377153 63078325 639577 570529 118112881 136219869 10152263 11752621 23363711 21925166 4584141 21988140 38100115 55665927 X 78869247 79370643 1143519 1183299 80012766 80553942 118112881 136219869 X 5503902 40979 -5003705 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 9986 9986 112014616 112024602 1000000 250000 0 0 1000000 1000000 1000000 1000000 4000000 6000000 10006 10905 11288 9986 42185 250000 250000 250000 250000 1000000 1500000 396680 396680 52206072 33465303 18740769 40598727 34179053 6419674 25557123 LIABILITY FOR PENSION BENEFITS 1780999 ESTIMATED THIRD PARTY SETTLEMENTS 1412053 MEDICARE ADVANCE PAYMENT - CURRENT 1291930 MEDICARE ADVANCE PAYMENT - LONG TERM 15052403 REFUNDABLE ADVANCE 2450755 21988140 105994453 40979 40979 105953474 11575030 11575030 117528504 100449572 0 100449572 11575030 11575030 112024602 PART XI, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 11,575,030. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 11,575,030. 1 1 1 X 1 X 1 1 0 0 700576 700576 0.00630 700576 700576 0.00630 1331880 1331880 0.01190 26701455 12141474 14559981 0.13000 28033335 12141474 15891861 0.14190 28733911 12141474 16592437 0.14820 1 5640216 31257460 34061802 -2804342 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 18 1 1 1 1 X WWW.RFGH.NET X 1 18 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:IN 2018, ANOTHER ROUND OF COMMUNITY NEED ASSESSMENT BEGAN THROUGH THE MAINE SHARED COMMUNITY HEALTH NEEDS ASSESSMENT (MAINE SHARED CHNA) - A COLLABORATION OF MULTIPLE HEALTHCARE SYSTEMS ACROSS MAINE AND THE MAINE CDC. THE MAINE SHARED CHNA COORDINATES STATE AND COUNTY HEALTH ASSESSMENTS. THIS EFFORT SATISFIES THE NEED FOR ALL TAX-EXEMPT HOSPITALS TO DO PERIODIC NEEDS ASSESSMENTS IN ORDER TO MEET FEDERAL COMMUNITY BENEFIT REQUIREMENTS; SUPPORTS STATE AND LOCAL PUBLIC HEALTH DEPARTMENT'S NATIONAL PUBLIC HEALTH ACCREDITATION REQUIREMENTS; AND PROVIDES VALUABLE POPULATION HEALTH ASSESSMENT DATA FOR A WIDE VARIETY OF ORGANIZATIONS ACROSS MAINE. BY DOING THIS TOGETHER, WE AVOID DUPLICATING OUR EFFORTS WHILE FOSTERING COLLABORATIVE PARTNERSHIPS. THE MAINE SHARED CHNA REPORTS PROVIDE UP-TO-DATE HEALTH INFORMATION AT THE STATE, COUNTY, URBAN, AND SUB-POPULATION LEVELS. ATTENDEES AT PUBLIC FORUMS HELD IN 2018 ACROSS THE 16 COUNTIES IN MAINE IDENTIFIED A LIST OF HEALTH ISSUES IN EACH OF THEIR COMMUNITIES. THE FORUM HELD IN SOMERSET COUNTY IDENTIFIED A LIST OF HEALTH ISSUES IN THAT COMMUNITY AS PRIORITY AREAS: MENTAL HEALTH, OLDER ADULT HEALTH/HEALTHY AGING, SUBSTANCE USE, AND SOCIAL DETERMINANTS OF HEALTH. 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 OF CENTRAL MAINE HEALTHCARE, EASTERN MAINE HEALTHCARE SYSTEMS, MAINEGENERAL HEALTH, MAINEHEALTH, AND THE MAINE CENTER FOR DISEASE CONTROL AND PREVENTION. THE MAINE SHARED CHNA WORKS TO IMPROVE THE HEALTH STATUS OF MAINE RESIDENTS AND TRACK RESULTS. RFGH HAS HAD ACTIVE REPRESENTATION ON THE COMMUNITY ENGAGEMENT TEAM OF THE PROJECT AND HAS ACTIVELY PARTICIPATED IN IDENTIFYING FORUM FOCUSES AND DEVELOPING FEEDBACK OPPORTUNITIES FROM THE FORUMS. REDINGTON-FAIRVIEW GENERAL HOSPITAL PART V, SECTION B, LINE 11: HOW THE HOSPITAL FACILITY IS ADDRESSING THE SIGNIFICANT NEEDS......:ATTACHED IS THE 2019 - 2020 RFGH COMMUNITY HEALTH WORK-PLAN. PART V, SECTION B, LINE 22D: HOW 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 48.73% 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 48.73% 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 3RD PARAGRAPH ON PAGE 13 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:REDINGTON-FAIRVIEW GENERAL HOSPITAL46 FAIRVIEW AVENUEPO BOX 468SKOWHEGAN, ME 04976207-474-5121CATEGORY A & B SLIDING FEE SCALEREDINGTON-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 A SLIDING FEE SCALE (CATEGORY B) AND OTHER PROGRAMS 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-THE WHITE BUILDING IN THE BACK PARKING LOT OF THE HOSPITAL. TO SPEAK TO A REPRESENTATIVE REGARDING THE APPLICATION PROCESS PLEASE CALL 858 8367. PLEASE NOTE THE OFFICE IS OPEN MONDAY FRIDAY 7AM 5PM.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 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 COVERAGE. IF YOU ARE NOT ELIGIBLE YOU WILL BE ISSUED A DENIAL AND MUST PROVIDE A COPY OF THE ENTIRE PACKET, INCLUDING A LIST OF ASSETS. {NOTE: THIS DENIAL LETTER IS ONLY GOOD FOR SIX MONTHS.}TO BE ELIGIBLE FOR FREE CARE (CATEGORY A) OR THE RFGH SLIDING FEE (CATEGORY B), YOUR FAMILY INCOME MUST BE BELOW THE FOLLOWING LEVELS. THE HOSPITAL WILL CONSIDER THE HIGHEST INCOME LEVEL AVAILABLE BASED ON THE NUMBER OF DEPENDENTS CLAIMED ON YOUR TAXES (SEE THE TABLES BELOW). IF YOU DO NOT QUALIFY FOR FREE CARE (CATEGORY A), 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. IN ADDITION, RFGH WILL PROVIDE YOU WITH A FINAL DETERMINATION OF YOUR ELIGIBILITY FOR ASSISTANCE WITHIN FIVE (5) WORKING DAYS OF YOUR REQUEST. IF YOU DO NOT QUALIFY FOR A FULL 100% RFGH DISCOUNT (CATEGORY B), A MONTHLY PAYMENT PLAN WILL BE CALCULATED BY THE PATIENT ACCOUNTS REPRESENTATIVE.YOU WILL NEED TO SIGN A PAYMENT AGREEMENT CONTRACT AND FAITHFULLY COMPLETE YOUR PAYMENT PORTION IN ORDER TO RECEIVE THE NEGOTIATED DISCOUNT. **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_______19,1402_______25,8603_______32,5804_______39,3005_______46,0206_______52,7407_______59,4608_______66,180FOR EACH ADDITIONAL PERSON, ADD $6,720 ANNUALLY.CATEGORY B RFGH SLIDING FEE SCALEDISCOUNT 100% 75% 50% 25% INCOME INCOME INCOME INCOME FAMILY SIZE TO TO TO TO1_____________30,624________35,104_______39,584_______44,0642_____________36,896________41,376_______45,856_______50,3363_____________43,168________47,648_______52,128_______56,6084_____________49,440________53,920_______58,400_______62,8805_____________55,712________60,192_______64,672_______69,1526_____________61,984________66,464_______70,944_______75,4247_____________68,256________72,736_______77,216_______81,6968_____________74,528________79,008_______83,488_______87,968FOR EACH ADDITIONAL PERSON, ADD $6,272 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.- TIED FOR THE HIGHEST UNEMPLOYMENT RATE 5.7% IN THE STATE (3.8% STATE AVG).- HIGH POVERTY RATES ARE PRESENT IN ALL AGE GROUPS.- NEARLY ONE QUARTER OF CHILDREN LIVE BELOW THE FEDERAL POVERTY LEVEL- FOR THE YEARS 2013-2017, 37% OF CHILDREN LIVED IN SINGLE PARENT FAMILIES.- THE MEDIAN HOUSEHOLD INCOME OF $40,484 IS $10,342 (20%) LESS THAN THE REST OF THE STATE AT $50,826. 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 MICHAEL CURRAN MD DIRECTOR 356977 0 119046 0 14721 0 3671 0 0 0 494415 0 0 0 MICHAEL LAMBKE MD DIRECTOR 175740 0 26440 0 14285 0 2516 0 0 0 218981 0 0 0 GINA GOMEZ MD DIRECTOR 297087 0 0 0 15795 0 5909 0 0 0 318791 0 0 0 RICHARD D WILLETT CEO/SECRETARY 373167 0 0 0 14710 0 9800 0 0 0 397677 0 0 0 DANA C KEMPTON ASSOCIATE DIRECTOR 281586 0 0 0 14715 0 8628 0 0 0 304929 0 0 0 ELMER DOUCETTE CFO 228884 0 0 0 14511 0 1646 0 0 0 245041 0 0 0 TIRUNELLAI R SHANKAR MD SURGEON 290309 0 304857 0 14721 0 2903 0 0 0 612790 0 0 0 AMIR BAIG MD ANESTHESIOLOGIST 383825 0 0 0 15885 0 3682 0 0 0 403392 0 0 0 JOHN COMIS MD ER PHYSICIAN 414704 0 0 0 15885 0 4294 0 0 0 434883 0 0 0 NANCY FLEMING MD ER PHYSICIAN 324813 0 0 0 15885 0 1341 0 0 0 342039 0 0 0 GANNA CHUGAY MD ANESTHESIOLOGIST 315477 0 0 0 15885 0 2750 0 0 0 334112 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 3227756 4202585 390171 4439445 47690 0 1 1 1 B 2000000 7500000 7500000 0 0 1 1 C 1410000 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 III, LINE 1: 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 SERVICES. 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 SEE SCHEDULE J FORM 990, PART VI, SECTION C, LINE 19 REDINGTON-FAIRVIEW GENERAL HOSPITAL MAKES ITS GOVERNING DOCUMENTS AND FINANIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART XI, LINE 9: EFFECT OF ASC 715 -5,003,705. 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