2025-09-29T08:15:32-05:00 2024-06-30 351178661 BLUE & CO LLC 500 N MERIDIAN ST SUITE 200 INDIANAPOLIS IN 46204 990 2023-07-01 350985964 LITTLE COMPANY OF MARY HOSPITAL OF INDIANA INC LITT 8124822345 800 WEST NINTH STREET JASPER IN 47546 MATHEW GAUG COO 8124822345 2025-09-26 1 1 EMILIE M KNIERIEM CPA P01330194 3176334705 2025-09-26 2023 2025-03-06 01:10:19Z MEMORIAL HOSPITAL & HEALTH CARE CTR KEITH MILLER 800 WEST NINTH STREET JASPER IN 47546 394031001 0 X WWW.DEACONESSMEMORIAL.COM X 1950 IN PROVIDE HEALTH SERVICES CONSISTENT WITH THE NEEDS OF THE COMMUNITY. 15 11 2174 165 44550 24843 2519189 1622074 261634222 275740636 7998946 7992343 8908870 5318228 281061227 290673281 158503 0 0 0 150605551 153265150 0 0 0 129087132 160250502 279851186 313515652 1210041 -22842371 311830608 359870735 100002840 95273749 211827768 264596986 X WE, THE BOARD, PHYSICIANS, STAFF, VOLUNTEERS AND AUXILIARY OF MEMORIAL HOSPITAL AND HEALTH CARE CENTER WILL PROVIDE EXCELLENT HEALTH CARE SERVICES TO THE PEOPLE OF THE COMMUNITIES WE SERVE. WE WILL PLEDGE OURSELVES TO CARE FOR EACH INDIVIDUAL IN A MANNER THAT REFLECTS THE PHYSICAL, PSYCHOLOGICAL AND SPIRITUAL HEALING MINISTRY OF JESUS CHRIST. WE WILL WORK TOGETHER TO CREATE AN ATMOSPHERE OF MUTUAL RESPECT, DIGNITY, COMPASSION AND JOY. WE WILL EFFECTIVELY AND EFFICIENTLY UTILIZE OUR RESOURCES IN PROVIDING HEALTH CARE. WE WILL BE GUIDED BY THE NEEDS OF THOSE WE SERVE AND AS NEEDS CHANGE, WE WILL CHANGE. WE WILL "BE FOR OTHERS!" 0 0 254034463 280215785 GENERAL PRIMARY ACUTE CARE HOSPITAL EXPENSES INCURRED IN PROVIDING EXCELLENT HEALTH CARE SERVICES CONSISTENT WITH THE NEEDS OF THE COMMUNITY. SEE FORM 990, SCHEDULE H FOR ADDITIONAL SERVICES PROVIDED TO THE COMMUNITY. 254034463 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 1 1 0 0 1 216 0 1 2174 1 1 1 0 0 0 0 0 0 0 0 0 0 0 X 15 11 0 0 0 0 1 1 1 1 1 0 0 0 1 1 1 1 1 1 1 0 IN X EDWARD W MILLER 8129960506 800 WEST NINTH STREET JASPER IN 47546 JIM HUEBNER BOARD CHAIRPERSON 5.00 0.00 X X 0 0 0 E KYLE BENNETT PRES & CEO PARTIAL YEAR 40.00 1.00 X X 614705 0 32902 BRENDA STALLINGS BOARD TREASURER 1.00 0.00 X X 0 0 0 SR RENEE CUNNINGHAM BOARD SECRETARY 30.00 1.00 X X 0 0 0 DONNA BALKA BOARD MEMBER 1.00 0.00 X 0 0 0 CHRISTIAN BLOME BOARD MEMBER 1.00 0.00 X 0 0 0 NEIL DAUBY BOARD MEMBER 1.00 0.00 X 0 0 0 TONYA HEIM BOARD MEMBER 1.00 0.00 X 0 0 0 GARY KEEPES MD BOARD MEMBER 1.00 0.00 X 0 0 0 SHERRIL LUEKEN BOARD MEMBER 1.00 0.00 X 0 0 0 SHAWN MCCOY BOARD MEMBER 1.00 0.00 X 0 0 0 KRISTI NORD MD MED. STAFF PRES. 1.00 0.00 X 0 0 0 SOHAIL QADIR MD BOARD MEMBER 1.00 40.00 X 614661 0 30028 LYNN LINGAFELTER BOARD MEMBER 1.00 0.00 X 0 0 0 JAMES PORTER MD BOARD MEMBER 1.00 0.00 X 0 0 0 NICK WERNE MD BOARD MEMBER 1.00 40.00 X 426909 0 35250 D RYAN PHILLIPS MD MED. STAFF PRES. PARTIAL YEAR 1.00 0.00 X 0 0 0 KENNETH SENDELWECK BOARD VICE CHAIR PARTIAL YEAR 1.00 1.00 X X 0 0 0 SR SHARON ANN WALSH PROVINCE LEADER PARTIAL YEAR 1.00 0.00 X 0 0 0 SCOTT BECKMAN MD BOARD MEMBER PARTIAL YEAR 1.00 0.00 X 0 0 0 EDWARD W MILLER VP FINANCE/CFO 40.00 1.00 X 392697 0 28228 LORI PERSOHN VP PT SVCS AND CNO 40.00 0.00 X 242395 0 23816 GEOFFREY DAY MD PHYSICIAN 40.00 0.00 X 1388605 0 29343 JOSHUA LEONARD MD PHYSICIAN 40.00 0.00 X 1364602 0 29343 ADAM DAWKINS MD PHYSICIAN 40.00 0.00 X 1419104 0 29343 KEITH CARVER PHYSICIAN 40.00 0.00 X 1094816 0 35250 MATTHEW DODARO PHYSICIAN 40.00 0.00 X 1127255 0 28425 8685749 0 301928 210 0 1 0 MEMORIAL HOSPITAL OUTPATIENT 600 WEST 13TH STREET JASPER IN 47546 MEDICAL SERVICES 4523630 MATRIX INTEGRATION LLC 417 MAIN ST JASPER IN 47546 IT SERVICES 3990379 MEDICAL SOLUTIONS LLC PO BOX 850737M OMAHA NE 68114 CONTRACTED LABOR 2310053 INDIANA UNIVERSITY PO BOX 78000 DETROIT MI 48278 MEDICAL SERVICES 1509409 ARUP LABORATORIES 500 CHIPETA WAY SALT LAKE CITY UT 84108 MEDICAL LABORATORY SERVICES 1164984 41 678196 308463 635415 1622074 NET PATIENT SERVICE REVENUE 621110 275740636 275740636 275740636 8332700 8332700 158548 246907 -88359 -88359 -88359 102770456 103110813 -340357 -340357 -340357 CAFETERIA REVENUE 900099 667638 667638 GAIN ON JOINT VENTURE 900099 318586 318586 MEM LAB OTHER REVENUE 621500 44550 44550 4375813 4156563 219250 5406587 290673281 280215785 44550 8790872 X 2291367 1892550 398817 127109913 104986175 22123738 1910439 1611951 298488 14142740 11933072 2209668 7810691 6590345 1220346 475989 273496 202493 75000 43094 31906 35542063 20421916 15120147 167310 93307 74003 1583835 1559942 23893 17770156 8579549 9190607 960461 535641 424820 2096075 2096075 15260867 12805832 2455035 1689025 941955 747070 HOSPITAL SUPPLIES AND D 44884006 44739572 144434 TRANSITION COSTS 23421637 19059936 4361701 HAF EXPENSE 13886050 13886050 DUES & SUB. 974335 792889 181446 1463693 1191116 272577 313515652 254034463 59481189 0 22087029 55715706 25676368 24975710 1736048 2277627 3727920 3587308 2926620 2752183 149899032 6328453 102596022 143570579 148703574 120692563 4377027 6299059 311830608 359870735 30400864 27600682 64344237 62380530 769702 769711 4488037 4522826 100002840 95273749 X 211827768 264596986 211827768 264596986 311830608 359870735 X -22842371 3500141 536432 71575016 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1224000 1224000 103912281 848816 103063465 44762751 5479637 39283114 143570579 RIGHT OF USE LIABILITY 2333825 RELATED PARTY PAYABLE 2189001 4522826 X PART X, LINE 2: ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA REQUIRE MANAGEMENT TO EVALUATE TAX POSITIONS TAKEN BY THE CORPORATION AND RECOGNIZE A TAX LIABILITY IF THE CORPORATION HAS TAKEN AN UNCERTAIN POSITION THAT MORE LIKELY THAN NOT WOULD NOT BE SUSTAINED UPON EXAMINATION BY VARIOUS FEDERAL AND STATE TAXING AUTHORITIES. MANAGEMENT HAS ANALYZED THE TAX POSITIONS TAKEN BY THE CORPORATION, AND HAS CONCLUDED THAT AS OF JUNE 30, 2024 AND 2023, THERE ARE NO UNCERTAIN POSITIONS TAKEN OR EXPECTED TO BE TAKEN THAT WOULD REQUIRE RECOGNITION OF A LIABILITY OR DISCLOSURE IN THE ACCOMPANYING CONSOLIDATED FINANCIAL STATEMENTS. THE CORPORATION IS SUBJECT TO ROUTINE AUDITS BY TAXING JURISDICTIONS; HOWEVER, THERE ARE CURRENTLY NO AUDITS FOR ANY TAX PERIODS IN PROGRESS. THESE INCOME TAX RETURNS ARE GENERALLY OPEN TO EXAMINATION BY THE RELEVANT TAXING AUTHORITIES FOR A PERIOD OF THREE YEARS FROM THE LATER OF THE DATE THE RETURN WAS FILED OR ITS DUE DATE (INCLUDING APPROVED EXTENSIONS). 1 1 X 1 X 1 X 1 1 0 1 1 1720008 1720008 0.00550 35055925 29629185 5426740 0.01730 36775933 29629185 7146748 0.02280 2997 2997 0.00000 848822 848822 0.00270 5344 5344 0.00000 2243 2243 0.00000 10854 10854 0.00000 870260 870260 0.00270 37646193 29629185 8017008 0.02550 10113823 47303829 51095447 -3791618 X 1 1 1 1 MEMORIAL HOSPITAL & HEALTH CARE CENTER 800 W 9TH ST JASPER IN 47546 WWW.MHHCC.ORG 24-005102-1 X X X MEMORIAL HOSPITAL & HEALTH CARE CENTER 1 0 0 1 X X X X X X X X X 23 1 0 0 1 X HTTPS://WWW.DEACONESSMEMORIAL.COM/COMMUNITY-NEEDS-ASSESSMENT/ X X 1 23 0 1 0 1 X 200.000000000000 400.000000000000 X 1 1 X X X 1 X HTTPS://WWW.DEACONESSMEMORIAL.COM/PATIENT-VISITORS/FINANCIAL-ASSISTANCE/ X HTTPS://WWW.DEACONESSMEMORIAL.COM/PATIENT-VISITORS/FINANCIAL-ASSISTANCE/ X HTTPS://WWW.DEACONESSMEMORIAL.COM/PATIENT-VISITORS/FINANCIAL-ASSISTANCE/ X X X X X 1 X 0 X X X X 1 X 0 0 MEMORIAL HOSPITAL & HEALTH CARE CENTER PART V, SECTION B, LINE 5: A SERIES OF FOCUS GROUP AND ADVISORY COUNCIL MEETINGS WERE CONDUCTED TO PROVIDE AN OPPORTUNITY AND FORUM FOR COMMUNITY REPRESENTATIVES TO PARTICIPATE IN IDENTIFYING HEALTH NEEDS. THERE WERE 123 PEOPLE THAT PARTICIPATED IN THE FOCUS GROUP FEEDBACK PROCESS FOR THE 2023 CHNA. THE ADVISORY COUNCILS WERE DEVELOPED IN 2023 AS A WAY FOR THE HOSPITAL TO STAY CONNECTED WITH EACH COUNTY OUTSIDE OF DUBOIS COUNTY AND MEET ON A CONTINUED BASIS TO UPDATE THE HOSPITAL ON COUNTY NEEDS. MEMORIAL HOSPITAL & HEALTH CARE CENTER PART V, SECTION B, LINE 7D: THE MOST CURRENT TWO COMMUNITY HEALTH NEEDS ASSESSMENTS ARE AVAILABLE ON THE HOSPITAL'S MAIN WEBPAGE LABELED COMMUNITY NEEDS. MEMORIAL HOSPITAL & HEALTH CARE CENTER PART V, SECTION B, LINE 11: THE MOST CURRENT IMPLEMENTATION STRATEGY FOR THE TAX YEAR 2023 IS THE 2023 IMPLEMENTATION STRATEGY WHICH COVERS THE TAX YEARS 2023, 2024, AND 2025.THE KEY HEALTH ISSUES BEING ADDRESSED WITH REGARDS TO THE CONDUCTED NEEDS ASSESSMENT ARE ACCESS TO PRIMARY CARE, ACCESS TO MENTAL HEALTH SERVICES, OPPORTUNITIES REGARDING WOMEN'S SERVICES RELATED TO MAMMOGRAPHY, AND EDUCATING THE COMMUNITY ON HEALTH CARE TOPICS TO ADDRESS KEY MORTALITY RATES.ACCESS TO HEALTHCARE:-RE-DEPLOY THE PROVIDERS WHO ARE ACCEPTING NEW PATIENTS IN AN ADVERTISING CAMPAIGN.-CONTINUE TO RECRUIT, DEVELOP, AND TRAIN RESIDENTS IN THE MEMORIAL HOSPITAL FAMILY MEDICINE RESIDENCY PROGRAM TO MEET THE LONG-TERM NEEDS OF SOUTHWESTERN INDIANA BY 'GROWING OUR OWN.'-DEPLOY VIRTUAL HEALTH FOR PRIMARY CARE.-RECRUIT PHYSICIANS BASED ON THE MEDICAL STAFF DEVELOPMENT PLAN.-IMPLEMENT AN ELECTRONIC HEALTH RECORD TO ASSIST WITH ACCESS TO CARE. ACCESS TO MENTAL HEALTH SERVICES:-PARTICIPATE IN THE HRSA GRANT IN MARTIN COUNTY IN PARTNERSHIP WITH INDIANA UNIVERSITY.-DETERMINE PARTNERS IN THE COMMUNITIES WE SERVE TO ADDRESS MENTAL HEALTH CONCERNS SPECIFICALLY AROUND SUBSTANCE ABUSE.EDUCATING THE COMMUNITY ON HEALTH CARE TOPICS:-CONTINUE OUTREACH PROGRAMMING TO EDUCATE THE COMMUNITIES WE SERVE ON CARDIOLOGY, ONCOLOGY, MAMMOGRAPHY, AND STROKE.-ACHIEVE PRIMARY STROKE CERTIFICATION. MEMORIAL HOSPITAL & HEALTH CARE CENTER PART V, SECTION B, LINE 13H: PRESUMPTIVE ELIGIBILITY FOR DECEASED AND INDIVIDUALS IN HOMELESS SITUATIONS. MEMORIAL HOSPITAL & HEALTH CARE CENTER PART V, SECTION B, LINE 24: GROSS CHARGES FOR NON-MEDICALLY NECESSARY SERVICES (ELECTIVE SERVICES) INCLUDING COSMETIC, SURGICAL WEIGHT LOSS, EXPERIMENTAL (NON-FDA APPROVED DEVICES) PROCEDURES, SPECIALTY REPLACEMENT LENSES, HEARING AIDS, SERVICES DENIED BY INSURANCE FOR NO PRIOR AUTHORIZATION OR NON-EMERGENCY SERVICES PROVIDED AS A RESULT OF BEING OUT-OF-NETWORK ARE NOT ELIGIBLE FOR DISCOUNTED CHARGES OR FINANCIAL ASSISTANCE. MEMORIAL HOSPITAL & HEALTH CARE CENTER: SCHEDULE H, PART V, LINE 7A:HTTPS://WWW.MHHCC.ORG/COMMUNITY-NEEDS-ASSESSMENT/ 1 1 - SLEEP LAB 721 W 13TH STREET STE 202 JASPER IN 47546 SLEEP LAB PART I, LINE 3C: A PATIENT MAY QUALIFY FOR PARTIAL FINANCIAL ASSISTANCE IF THE PATIENT'S HOUSEHOLD INCOME IS BETWEEN 200% AND 400% OF THE FEDERAL POVERTY GUIDELINES. PRESUMPTIVE ELIGIBILITY FOR FREE CARE WITH REQUIRED VERIFICATION IS AVAILABLE FOR DECEASED INDIVIDUALS WITH NO ESTATE AND NO SURVIVING SPOUSE; AND, FOR INDIVIDUALS IN HOMELESS SITUATIONS RECEIVING ASSISTANCE FROM SUPPORTIVE SERVICES SUCH AS GOVERNMENTAL, RELIGIOUS OR COMMUNITY SERVICES. PART I, LINE 7: MEMORIAL HOSPITAL AND HEALTH CARE CENTER CALCULATED THE COST OF FINANCIAL ASSISTANCE AND MEANS-TESTED GOVERNMENT PROGRAMS, USING THE COST-TO-CHARGE RATIO DERIVED FROM SCHEDULE H, WORKSHEET 2, RATIO OF PATIENT CARE COST-TO- HARGES. OTHER BENEFIT AMOUNTS REPORTED ON LINE 7 WERE CALCULATED USING COSTS CHARGED DIRECTLY TO THE INDIVIDUAL PROGRAMS VIA THE FINANCIAL ACCOUNTING SYSTEM. PART I, LINE 7G: THE ORGANIZATION DOES NOT PROVIDE ANY SUBSIDIZED HEALTH SERVICES ATTRIBUTABLE TO PHYSICIAN CLINICS. PART III, LINE 2: MEMORIAL HOSPITAL AND HEALTH CARE'S ANALYSIS AND ASSESSMENT OF THE BAD DEBT EXPENSE IS BASED ON THE EVALUATION OF ITS MAJOR PAYOR SOURCES OF REVENUE, THE AGING OF THE ACCOUNTS, HISTORICAL LOSSES, CURRENT ECONOMIC CONDITIONS, AND OTHER FACTORS UNIQUE TO ITS SERVICE AREA AND THE HEALTHCARE INDUSTRY. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THE MAJOR PAYOR SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS. PART III, LINE 3: PART III, SECTION A. BAD DEBT EXPENSE CONSIDERED COMMUNITY BENEFIT: NO OTHER BAD DEBT AMOUNTS HAVE BEEN INCLUDED AS COMMUNITY BENEFIT. THE HOSPITAL HAS A DETAILED FINANCIAL ASSISTANCE POLICY AND EDUCATES PATIENTS WITH LIMITED ABILITY TO PAY REGARDING FINANCIAL ASSISTANCE. FOR THIS REASON, THE ORGANIZATION BELIEVES IT ACCURATELY CAPTURES ALL CHARITY CARE DEDUCTIONS PROVIDED ACCORDING TO THE FINANCIAL ASSISTANCE POLICY AND THE AMOUNT OF BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY IS NEGLIGIBLE. PART III, LINE 4: FOOTNOTE TO ORGANIZATION'S FINANCIAL STATEMENTS THAT DESCRIBES BAD DEBT EXPENSE: SEE PAGE 15 OF THE AUDITED FINANCIAL STATEMENTS FOOTNOTE 3 UNDER HEADING "PATIENT SERVICE REVENUE" PART III, LINE 8: THE SOURCE USED TO DETERMINE THE AMOUNT OF MEDICARE ALLOWABLE COSTS REPORTED FOR PART III, SECTION B, MEDICARE HAS BEEN PROVIDED FROM THE YEAR ENDED JUNE 30, 2024: HOSPITAL STATEMENT OF REIMBURSABLE COST. PART III, LINE 9B: THE ORGANIZATION'S WRITTEN DEBT COLLECTION POLICY INCLUDES PROVISIONS ON THE COLLECTION PRACTICES TO BE FOLLOWED DURING THE FOLLOW-UP PERIOD AFTER A PATIENT IS DISCHARGED AND INCLUDES SPECIFIC INSTRUCTIONS FOR SELF-PAY WHO MAY QUALIFY FOR CHARITY CARE OR FINANCIAL ASSISTANCE. PART VI, LINE 2: NEEDS ASSESSED: IN ADDITION TO THE COMMUNITY HEALTH NEEDS ASSESSMENT CONDUCTED EVERY THREE YEARS. THE ORGANIZATION ASSESSES THE HEALTH CARE NEEDS OF THE COMMUNITY IT SERVES WITH HOSPITAL COMMITTEES DEVELOPING STRATEGIC PLANS FOR THE HOSPITAL TO PROVIDE QUALITY CARE TO THE COMMUNITY MEMBERS. ADDITIONALLY, IN 2014, THE HOSPITAL IMPLEMENTED ADVISORY COUNCILS WITH THE ADJACENT COUNTIES TO DUBOIS COUNTY, INDIANA, AND MANAGEMENT COLLABORATES AND OBTAINS ONGOING FEEDBACK FOR NEEDED ASSISTANCE WITH THESE COUNCILS. THE COUNCIL'S PARTICIPANTS INCLUDE ECONOMIC DEVELOPMENT DIRECTORS, COUNTY HEALTH NURSE, CHAMBER OF COMMERCE LEADERS, EDUCATORS, EXECUTIVES, PASTORS, EMS, SHERIFFS, BUSINESS OWNERS, AND OTHER HEALTH CARE ORGANIZATION LEADERS. PART VI, LINE 3: PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE:APPROPRIATE SIGNAGE IS VISIBLE IN THE HOSPITAL AND ALL HOSPITAL-OWNED FACILITIES, SPECIFICALLY IN PATIENT ACCESS AREAS, CREATING AWARENESS FOR THE FINANCIAL ASSISTANCE PROGRAM AND THE FINANCIAL ASSISTANCE THAT IS AVAILABLE. THE FINANCIAL ASSISTANCE POLICY, APPLICATION, AND PLAIN LANGUAGE SUMMARY (COLLECTIVELY THE "FAP PACKET") ARE AVAILABLE FOR DOWNLOAD AT THE HOSPITAL'S WEBSITE PROVIDED IN SCH H, PART V. THE FAP PACKET CAN BE OBTAINED FREE OF CHARGE FROM THE HOSPITAL'S MAIN REGISTRATION DESK, THE REGISTRATION AREA OF THE EMERGENCY ROOM, OR THE CASHIER/FINANCIAL COUNSELOR'S OFFICE. REQUESTS FOR THE FAP PACKET CAN BE MADE VIA EMAILING FINANCIALASSISTANCE@MHHCC.ORG OR BY CALLING 812-996-0413. PART VI, LINE 4: DESCRIPTION OF COMMUNITY:AS A REGIONAL HEALTH CENTER, THE STAFF PROVIDES A COMPREHENSIVE RANGE OF MEDICAL CARE FOR RESIDENTS OF DUBOIS AND SURROUNDING COUNTIES WITH A POPULATION OF APPROXIMATELY 168,000 WITH AVERAGE HOUSEHOLDS RANGING BETWEEN 5,000 TO 16,200 FOR THE COUNTIES. THE UNEMPLOYMENT RATE HAS BEEN BETWEEN 3.1 AND 4.4 AND PERSONAL PER CAPITAL INCOME RANGES BETWEEN $36,000 AND $51,000. THE POVERTY RATE RANGES FROM 7.6 TO 11.1. MORE THAN 80% OF THE ADULTS HAVE HIGH SCHOOL DIPLOMAS AND OVER 10% HAVE BACHELOR'S DEGREES. IN DUBOIS COUNTY THE PERCENT IS HIGHER WITH 18.7% OF ADULTS AGED 25 AND OLDER HAVING BACHELOR'S DEGREAS OR MORE EDUCATION. LESS THAN 7% OF THE POPULATION IS REPORTED AS HISPANIC. PART VI, LINE 5: OTHER COMMUNITY HEALTH PROMOTION:THE ORGANIZATION FURTHERS ITS EXEMPT PURPOSE BY PROMOTING HEALTH OF THE COMMUNITY THROUGH THE FOLLOWING: THE MAJORITY OF THE ORGANIZATION'S GOVERNING BODY IS COMPRISED OF PERSONS WHO RESIDE IN THE ORGANIZATION'S PRIMARY SERVICE AREA. ANY SURPLUS FUNDS ARE APPLIED DIRECTLY OR INDIRECTLY TO IMPROVE PATIENT CARE SERVICES. ALSO, THE ORGANIZATION OPERATES UNDER THE PREMISE OF AN OPEN MEDICAL STAFF WITH REGARD TO QUALIFIED PHYSICIANS IN THE 9 COUNTY COMMUNITY IT SERVES, HOWEVER IT DOES NOT ACTIVELY PURSUE THOSE PHYSICIANS WHO HAVE NOT APPROACHED THE ORGANIZATION REGARDING THESE PRIVILEGES. PART VI, LINE 6: AFFILIATED HEALTH CARE SYSTEM:NOT APPLICABLE. THE ORGANIZATION IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM. PART VI, LINE 7, REPORTS FILED WITH STATES IN X X X X 0 1 0 0 0 0 0 0 0 ADAM DAWKINS MD PHYSICIAN 730000 0 534871 0 154233 0 6100 0 23243 0 1448447 0 0 0 GEOFFREY DAY MD PHYSICIAN 737042 0 458172 0 193391 0 6100 0 23243 0 1417948 0 0 0 JOSHUA LEONARD MD PHYSICIAN 722656 0 454477 0 187469 0 6100 0 23243 0 1393945 0 0 0 MATTHEW DODARO PHYSICIAN 495424 0 576331 0 55500 0 6100 0 22325 0 1155680 0 0 0 KEITH CARVER PHYSICIAN 489685 0 576331 0 28800 0 6100 0 29150 0 1130066 0 0 0 E KYLE BENNETT PRES & CEO PARTIAL YEAR 593705 0 0 0 21000 0 6100 0 26802 0 647607 0 0 0 SOHAIL QADIR MD BOARD MEMBER 594858 0 0 0 19803 0 6100 0 23928 0 644689 0 0 0 NICK WERNE MD BOARD MEMBER 279580 0 136401 0 10928 0 6100 0 29150 0 462159 0 0 0 EDWARD W MILLER VP FINANCE/CFO 377697 0 0 0 15000 0 6100 0 22128 0 420925 0 0 0 LORI PERSOHN VP PT SVCS AND CNO 234589 0 0 0 7806 0 4293 0 19523 0 266211 0 0 0 PART I, LINE 4B A 457B SUPPLEMENTAL NON-QUALIFIED RETIREMENT PLAN WAS AVAILABLE FOR ELIGIBLE INDIVIDUALS TO PARTICIPATE IN. NO CONTRIBUTIONS TO THE PLAN WERE PAID BY THE HOSPITAL. INDIVIDUALS ELIGIBLE FOR THE PLAN INCLUDED PHYSICIANS EMPLOYED BY MEMORIAL HOSPITAL, PRESIDENT & CEO, EXECUTIVE VP & COO, VP & CFO, VP OF AMBULATORY SERVICES, VP AND CHIEF NURSING OFFICER, VP MEDICAL PRACTICE MANAGEMENT AND SUPPORT SERVICES. NO PAYMENTS FROM THE PLAN WERE MADE TO ANY LISTED INDIVIDUALS IN 2023. A HOSPITAL AUTHORITY OF THE CITY OF JASPER 351692946 2021-04-06 63470000 SEE PART VI 0 0 0 A 1685000 63470000 42859717 598033 20012250 2022 1 0 1 1 A 0 0 0 0 0 0 1 A 0 0 1 0 1 0 0 0 1 A 1 PART I, COLUMN (F), DESCRIPTION OF PURPOSE: A PORTION OF THE PROCEEDS OF THE SERIES 2021 BONDS WERE USED FOR THE PURPOSE OF REFUNDING A PORTION OF THE SERIES 2013 BONDS. IN ADDITION, THE REMAINING PORTION OF THE SERIES 2021 BONDS, AS OF JUNE 30, 2021, WERE USED FOR THE PURPOSE OF FINANCING A PORTION OF THE COSTS OF CONSTRUCTION, EQUIPPING, AND RENOVATION AND IMPROVEMENT OF CERTAIN FACILITIES OF THE CORPORATION. BRENDA STALLINGS SEE PART V 3736131 SEE PART V 0 SISTER RENEE CUNNINGHAM SEE PART V 210983 SEE PART V 0 SCHEDULE L, PART IV, BUSINESS TRANSACTIONS INVOLVING INTERESTED PERSONS: (A) NAME OF PERSON: BRENDA STALLINGS(B) RELATIONSHIP BETWEEN INTERESTED PERSON AND THE HOSPITAL: BRENDA STALLINGS, MEMORIAL HOSPITAL BOARD MEMBER, IS THE PRESIDENT OF MATRIX INTEGRATION.(D) DESCRIPTION OF TRANSACTION: MATRIX INTEGRATION PROVIDES PROFESSIONAL INFORMATION TECHNOLOGY (IT) SERVICES TO MEMORIAL HOSPITAL. THE HOSPITAL PAID $3,736,131 FOR SERVICES TO MATRIX INTEGRATION IN THE CURRENT YEAR.(A) NAME OF PERSON: SISTER RENEE CUNNINGHAM (B) RELATIONSHIP BETWEEN INTERESTED PERSON AND THE HOSPITAL: SISTER RENEE CUNNINGHAM, MEMORIAL HOSPITAL BOARD MEMBER, PROVIDES NURSING SERVICES TO MEMORIAL HOSPITAL AS PART OF HER SPONSORSHIP THROUGH LITTLE COMPANY OF MARY SISTERS-USA, MEMORIAL HOSPITAL'S CORPORATE MEMBER. (D) DESCRIPTION OF TRANSACTION: THE HOSPITAL PAYS LITTLE COMPANY OF MARY SISTERS-USA $210,983 AS A SPONSORSHIP FOR SISTER RENEE CUNNINGHAM. THE SISTER PROVIDES NURSING SERVICES TO THE HOSPITAL AND SERVES AS A BOARD MEMBER. THE SISTER DOES NOT ACCEPT COMPENSATION AS SHE HAS TAKEN A VOW OF POVERTY. FORM 990, PART VI, SECTION A, LINE 6 THE SOLE MEMBER OF THE CORPORATION IS THE LITTLE COMPANY OF MARY SISTERS-USA. FORM 990, PART VI, SECTION A, LINE 7A LITTLE COMPANY OF MARY HOSPITAL BOARD MEMBERS HAS THE ABILITY TO NOMINATE AND APPROVE NEW MEMBERS TO THE BOARD. FORM 990, PART VI, SECTION A, LINE 7B THE FOLLOWING DECISIONS OF THE GOVERNING BODY ARE SUBJECT TO APPROVAL BY THE MEMBER: TO ESTABLISH/APPROVE THE MISSION/PHILOSOPHY OF THE CORPORATION; TO ADOPT, AMEND OR REPEAL THE ARTICLES OF INCORPORATION OR BYLAWS OF THE CORPORATION; TO FIX THE NUMBER OF DIRECTORS OF THE CORPORATION AND APPOINT THE CORPORATION'S BOARD OF DIRECTORS; TO REMOVE ANY MEMBER OF THE BOARD OF THE CORPORATION; TO APPOINT AND REMOVE THE PRESIDENT/CEO OF THE CORPORATION; TO APPOINT AND REMOVE THE CHAIRPERSON OF THE BOARD OF DIRECTORS; TO APPROVE FOR THE CORPORATION, THE ACQUISITION OF ASSETS, THE INCURRENCE OF INDEBTEDNESS OR THE LEASE, SALE, TRANSFER, ASSIGNMENT, OR ENCUMBERING OF THE ASSETS IN AN AMOUNT SET FROM TIME TO TIME BY THE MEMBERS; TO APPROVE THE MERGER, DISSOLUTION, AFFILIATION, OR CORPORATE RESTRUCTURING OF THE CORPORATION AND ANY SUBSIDIARY OF THE CORPORATION; TO ACCEPT A GIFT OR LEGACY IMPOSING A PERMANENT OR CONTINUING OBLIGATION ON THE CORPORATION; TO APPROVE THE ANNUAL OPERATING AND CAPITAL BUDGETS; AND TO APPOINT THE AUDITORS OF THE CORPORATION. FORM 990, PART VI, SECTION B, LINE 11B THE PROCESS FOR REVIEWING THE FORM 990 INCLUDES A REVIEW BY THE DIRECTOR OF FINANCE AND CHIEF FINANCIAL OFFICER. A COPY OF THE FORM 990 IS MADE AVAILABLE FOR THE BOARD OF DIRECTORS FOR REVIEW UPON REQUEST. FORM 990, PART VI, SECTION B, LINE 12C THE BOARD CHAIRPERSON EVALUATES SITUATIONS WHERE POSSIBLE CONFLICTS MAY EXIST, BOARD MEMBERS ARE INFORMED OF ANY POTENTIAL CONFLICT OF INTEREST PRIOR TO DISCUSSIONS TAKE PLACE AT THE BOARD MEETING. FORM 990, PART VI, SECTION B, LINE 15 THE PROCESS FOR DETERMINING THE COMPENSATION FOR ORGANIZATION'S OFFICERS IS CONDUCTED BY THE COMPENSATION COMMITTEE. THE COMPENSATION COMMITTEE, COMPOSED OF THE BOARD'S EXECUTIVE COMMITTEE EXCLUDING THE CEO, REVIEWS EXTERNAL SURVEY INFORMATION PROVIDED BY AN INDEPENDENT COMPENSATION CONSULTANT, AND VOTES ON ANY COMPENSATION AND BENEFIT CHANGES FOR THE CEO AND APPROVES THE SAME FOR OTHER MEMBERS OF ADMINISTRATIVE STAFF. THESE ACTIONS ARE DOCUMENTED IN MEETING MINUTES. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION DOES NOT MAKE THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, OR FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC. FORM 990, PART IX, LINE 11G PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 20,421,916. MANAGEMENT AND GENERAL EXPENSES 15,120,147. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 35,542,063. FORM 990, PART XI, LINE 9: ADJUSTMENT TO BASIS - PPE 71,575,016. PART XI, LINE 2C, OVERSIGHT OF THE AUDIT: THE FINANCE COMMITTEE ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF THE FINANCIAL STATEMENTS; NO PROCESSES HAVE CHANGED FROM THE PRIOR YEAR. THE AUDITORS ARE SELECTED BY THE COUNCIL MEMBERS OF THE AMERICAN PROVIDENCE OF LITTLE COMPANY OF MARY SISTERS. MEMORIAL HOSPITAL FOUNDATION INC 800 WEST NINTH STREET JASPER IN 47546 351359445 BENEFIT MEMORIAL HOSPITAL & HEALTH CARE CENTER IN 501(C)(3) LINE 12A, I MEMORIAL HOSPITAL AND HEALTH CARE CENTER 1 MEMORIAL HOSPITAL OUTPATIENT SURGERY CENTER MANAGEMENT COMPANY 600 WEST 13TH STREET JASPER IN 47546 274828606 SURGERY CENTER MANAGEMENT IN N/A RELATED 334235 531567 0 1 0.40000 0 0 1 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 MEMORIAL HOSPITAL FOUNDATION INC C 678196 CASH