FAIRFIELD MEMORIAL HOSPITAL ASSOCIATION: Form 990, tax year 2015
View the entire original 990 at ProPublica ↗
- Organization
- FAIRFIELD MEMORIAL HOSPITAL ASSOCIATION (EIN 37-0661202)
- Tax period
- 2015-07-01 to 2016-06-30
- Filed
- 2017-02-14
- IRS object ID
- 201700459349303285
- Schema version
- 2015v3.0
- 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
- Form 990
- Schedule A
- Schedule B
- Schedule D
- Schedule H
- Schedule J
- Schedule L
- Schedule O
- Schedule R
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return | 2017-02-14T15:59:33-06:00 | ReturnTs |
| Tax Period End | 2016-06-30 | TaxPeriodEndDt |
Preparer Firm PreparerFirmGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Firm EIN | 430352985 | PreparerFirmEIN |
Preparer Firm Name PreparerFirmName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | KERBER ECK & BRAECKEL LLP | BusinessNameLine1Txt |
Preparer US Address PreparerUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 1116 W MAIN ST | AddressLine1Txt |
| City | CARBONDALE | CityNm |
| State Abbreviation | IL | StateAbbreviationCd |
| ZIP | 629012335 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnTypeCd |
| Tax Period Begin | 2015-07-01 | TaxPeriodBeginDt |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 370661202 | EIN |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | FAIRFIELD MEMORIAL HOSPITAL ASSOC | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Control | FAIR | BusinessNameControlTxt |
| Phone | 6188422611 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 303 NW 11TH STRT | AddressLine1Txt |
| City | FAIRFIELD | CityNm |
| State Abbreviation | IL | StateAbbreviationCd |
| ZIP | 62837 | ZIPCd |
Business Officer BusinessOfficerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | KATHERINE BUNTING | PersonNm |
| Person Title | CEO | PersonTitleTxt |
| Phone | 6188422611 | PhoneNum |
| Signature | 2017-02-10 | SignatureDt |
| Discuss With Paid Preparer | Yes (true) | DiscussWithPaidPreparerInd |
Preparer Person PreparerPersonGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Person | ANNA GUETERSLOH | PreparerPersonNm |
| PTIN | P01315485 | PTIN |
| Phone | 6185291040 | PhoneNum |
| Preparation | 2017-02-14 | PreparationDt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax | 2015 | TaxYr |
| Build TS | 2017-02-10 21:41:12Z | BuildTS |
Form 990 IRS990
| Field | Value | IRS element (for citing) |
|---|---|---|
| Principal Officer | KATHERINE BUNTING | PrincipalOfficerNm |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 303 NW 11TH ST | AddressLine1Txt |
| City | FAIRFIELD | CityNm |
| State Abbreviation | IL | StateAbbreviationCd |
| ZIP | 62837 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | $28,865,803 | GrossReceiptsAmt |
| Group Return For Affiliates | false | GroupReturnForAffiliatesInd |
| Organization501c3 | Yes (X) | Organization501c3Ind |
| Website Address | WWW.FAIRFIELDMEMORIAL.ORG | WebsiteAddressTxt |
| Type Of Organization Corp | Yes (X) | TypeOfOrganizationCorpInd |
| Formation | 1943 | FormationYr |
| Legal Domicile State | IL | LegalDomicileStateCd |
| Activity Or Mission | THE MISSION OF FAIRFIELD MEMORIAL HOSPITAL IS TO MAINTAIN AND IMPROVE THE HEALTH OF THE COMMUNITIES WE SERVE. | ActivityOrMissionDesc |
| Voting Members Governing Body | 9 | VotingMembersGoverningBodyCnt |
| Voting Members Independent | 7 | VotingMembersIndependentCnt |
| Total Employee | 356 | TotalEmployeeCnt |
| Total Volunteers | 53 | TotalVolunteersCnt |
| Total Gross UBI | $0 | TotalGrossUBIAmt |
| PY Contributions Grants | $554,388 | PYContributionsGrantsAmt |
| CY Contributions Grants | $264,072 | CYContributionsGrantsAmt |
| PY Program Service Revenue | $27,127,241 | PYProgramServiceRevenueAmt |
| CY Program Service Revenue | $27,788,161 | CYProgramServiceRevenueAmt |
| PY Investment Income | $31,240 | PYInvestmentIncomeAmt |
| CY Investment Income | $179,090 | CYInvestmentIncomeAmt |
| PY Other Revenue | $808,385 | PYOtherRevenueAmt |
| CY Other Revenue | $634,480 | CYOtherRevenueAmt |
| PY Total Revenue | $28,521,254 | PYTotalRevenueAmt |
| CY Total Revenue | $28,865,803 | CYTotalRevenueAmt |
| CY Grants And Similar Paid | $0 | CYGrantsAndSimilarPaidAmt |
| CY Benefits Paid To Members | $0 | CYBenefitsPaidToMembersAmt |
| PY Salaries Comp Emp Bnft Paid | $13,584,090 | PYSalariesCompEmpBnftPaidAmt |
| CY Salaries Comp Emp Bnft Paid | $14,691,476 | CYSalariesCompEmpBnftPaidAmt |
| CY Total Prof Fndrsng Expns | $0 | CYTotalProfFndrsngExpnsAmt |
| CY Total Fundraising Expense | $0 | CYTotalFundraisingExpenseAmt |
| PY Other Expenses | $14,079,425 | PYOtherExpensesAmt |
| CY Other Expenses | $14,316,653 | CYOtherExpensesAmt |
| PY Total Expenses | $27,663,515 | PYTotalExpensesAmt |
| CY Total Expenses | $29,008,129 | CYTotalExpensesAmt |
| PY Revenues Less Expenses | $857,739 | PYRevenuesLessExpensesAmt |
| CY Revenues Less Expenses | -$142,326 | CYRevenuesLessExpensesAmt |
| Total Assets BOY | $25,680,755 | TotalAssetsBOYAmt |
| Total Assets EOY | $25,775,734 | TotalAssetsEOYAmt |
| Total Liabilities BOY | $10,857,590 | TotalLiabilitiesBOYAmt |
| Total Liabilities EOY | $11,025,865 | TotalLiabilitiesEOYAmt |
| Net Assets Or Fund Balances BOY | $14,823,165 | NetAssetsOrFundBalancesBOYAmt |
| Net Assets Or Fund Balances EOY | $14,749,869 | NetAssetsOrFundBalancesEOYAmt |
| Info In Schedule O Part III | Yes (X) | InfoInScheduleOPartIIIInd |
| Mission | THE MISSION OF FAIRFIELD MEMORIAL HOSPITAL IS TO MAINTAIN AND IMPROVE THE HEALTH OF THE COMMUNITIES WE SERVE. | MissionDesc |
| Significant New Program Srvc | false | SignificantNewProgramSrvcInd |
| Significant Change | false | SignificantChangeInd |
| Expense | $29,008,129 | ExpenseAmt |
| Revenue | $28,601,731 | RevenueAmt |
| Desc | AS A NOT-FOR-PROFIT COMMUNITY HOSPITAL, FAIRFIELD MEMORIAL HOSPITAL IS A CHARITABLE ORGANIZATION THAT EXISTS TO ADVANCE THE HEALTH OF THE RESIDENTS OF WAYNE COUNTY AND SURROUNDING COMMUNITIES. FAIRFIELD MEMORIAL HOSPITAL OPERATES A RURAL HEALTHCARE FACILITY WITH 25 ACUTE CARE BEDS AND 30 SKILLED CARE BEDS. IN AUGUST 2008 THE HOPSITAL OPENED AN OUTPATIENT PHYSICIAN CLINIC. FAIRFIELD MEMORIAL HOSPITAL PROVIDES QUALITY MEDICAL HEALTHCARE REGARDLESS OF RACE, CREED, SEX, NATIONAL ORGIN, HANDICAP, AGE OR ABILITY TO PAY. ALTHOUGH REIMBURSEMENT FOR SERVICES RENDERED IS CRITICAL TO THE OPERATION AND STABILITY OF FAIFIELD MEMORIAL HOSPITAL, IT IS RECOGNIZED THAT NOT ALL INDIVIDUALS POSSESS THE ABILITY TO PURCHASE ESSENTIAL MEDICAL SERVICES. THEREFORE, IN KEEPING WITH THIS CORPORATION'S COMMITMENT TO SERVE ALL MEMBERS OF THE COMMUNITY, FREE CARE AND/OR SUBSIDIZED CARE,CARE PROVIDED TO PERSONS COVERED BY GOVERNMENTAL PROGRAMS AT BELOW COST,AND HEALTH ACTIVITIES AND PROGRAMS TO SUPPORT THE COMMUNITY WILL BE CONSIDERED WHERE THE NEED AND/OR INDIVIDUALS INABILITY TO PAY COEXISTS. THE COMMUNITY BENEFITS CAN BE MEASURED IN MANY WAYS INCLUDING: DIRECT PATIENT CARE, SCREENINGS, EDUCATION, FUNDRAISING, AND COMMUNITY SERVICE EFFORTS OF OUR COLLEAGUES. THE HOSPITAL PROVIDES CARE TO PERSONS COVERED BY GOVERNMENTAL PROGRAMS, PROVIDING SERVICES TO BOTH MEDICARE AND MEDICAID PATIENTS. CHARITY CARE IS ALSO PROVIDED THROUGH THE HOSPITAL'S INTERNAL POLICY. | Desc |
| Total Program Service Expenses | $29,008,129 | TotalProgramServiceExpensesAmt |
| Described In Section501c3 | Yes (true) | DescribedInSection501c3Ind |
| Schedule B Required | Yes (true) | ScheduleBRequiredInd |
| Political Campaign Acty | false | PoliticalCampaignActyInd |
| Lobbying Activities | false | LobbyingActivitiesInd |
| Subject To Proxy Tax | false | SubjectToProxyTaxInd |
| Donor Advised Fund | false | DonorAdvisedFundInd |
| Conservation Easements | false | ConservationEasementsInd |
| Collections Of Art | false | CollectionsOfArtInd |
| Credit Counseling | false | CreditCounselingInd |
| Temp Or Permanent Endowments | false | TempOrPermanentEndowmentsInd |
| Report Land Building Equipment | Yes (true) | ReportLandBuildingEquipmentInd |
| Report Investments Other Sec | false | ReportInvestmentsOtherSecInd |
| Report Program Related Invst | false | ReportProgramRelatedInvstInd |
| Report Other Assets | false | ReportOtherAssetsInd |
| Report Other Liabilities | Yes (true) | ReportOtherLiabilitiesInd |
| Include FIN48 Footnote | Yes (true) | IncludeFIN48FootnoteInd |
| Independent Audit Fincl Stmt | Yes (true) | IndependentAuditFinclStmtInd |
| Consolidated Audit Fincl Stmt | false | ConsolidatedAuditFinclStmtInd |
| School Operating | false | SchoolOperatingInd |
| Foreign Office | false | ForeignOfficeInd |
| Foreign Activities | false | ForeignActivitiesInd |
| More Than5000 K To Org | false | MoreThan5000KToOrgInd |
| More Than5000 K To Individuals | false | MoreThan5000KToIndividualsInd |
| Professional Fundraising | false | ProfessionalFundraisingInd |
| Fundraising Activities | false | FundraisingActivitiesInd |
| Gaming Activities | false | GamingActivitiesInd |
| Operate Hospital | Yes (true) | OperateHospitalInd |
| Audited Financial Stmt Att | Yes (true) | AuditedFinancialStmtAttInd |
| Grants To Organizations | false | GrantsToOrganizationsInd |
| Grants To Individuals | false | GrantsToIndividualsInd |
| Schedule J Required | Yes (true) | ScheduleJRequiredInd |
| Tax Exempt Bonds | false | TaxExemptBondsInd |
| Engaged In Excess Benefit Trans | false | EngagedInExcessBenefitTransInd |
| PY Excess Benefit Trans | false | PYExcessBenefitTransInd |
| Loan Outstanding | Yes (true) | LoanOutstandingInd |
| Grant To Related Person | false | GrantToRelatedPersonInd |
| Business Rln With Org Mem | false | BusinessRlnWithOrgMemInd |
| Business Rln With Fam Mem | Yes (true) | BusinessRlnWithFamMemInd |
| Business Rln With Officer Ent | false | BusinessRlnWithOfficerEntInd |
| Deductible Non Cash Contri | false | DeductibleNonCashContriInd |
| Deductible Art Contribution | false | DeductibleArtContributionInd |
| Terminate Operations | false | TerminateOperationsInd |
| Partial Liquidation | false | PartialLiquidationInd |
| Disregarded Entity | false | DisregardedEntityInd |
| Related Entity | Yes (true) | RelatedEntityInd |
| Related Organization Ctrl Ent | false | RelatedOrganizationCtrlEntInd |
| Trnsfr Exmpt Non Chrtbl Rltd Org | false | TrnsfrExmptNonChrtblRltdOrgInd |
| Activities Conducted Prtshp | false | ActivitiesConductedPrtshpInd |
| Schedule O Required | Yes (true) | ScheduleORequiredInd |
| IRP Document | 25 | IRPDocumentCnt |
| IRP Document W2 G | 0 | IRPDocumentW2GCnt |
| Employee | 356 | EmployeeCnt |
| Employment Tax Returns Filed | Yes (true) | EmploymentTaxReturnsFiledInd |
| Unrelated Bus Incm Over Limit | false | UnrelatedBusIncmOverLimitInd |
| Foreign Financial Account | false | ForeignFinancialAccountInd |
| Prohibited Tax Shelter Trans | false | ProhibitedTaxShelterTransInd |
| Taxable Party Notification | false | TaxablePartyNotificationInd |
| Nondeductible Contributions | false | NondeductibleContributionsInd |
| Quid Pro Quo Contributions | false | QuidProQuoContributionsInd |
| Form8282 Property Disposed Of | false | Form8282PropertyDisposedOfInd |
| Rcv Fnds To Pay Prsnl Bnft Cntrct | false | RcvFndsToPayPrsnlBnftCntrctInd |
| Pay Premiums Prsnl Bnft Cntrct | false | PayPremiumsPrsnlBnftCntrctInd |
| Indoor Tanning Services | false | IndoorTanningServicesInd |
| Info In Schedule O Part VI | Yes (X) | InfoInScheduleOPartVIInd |
| Governing Body Voting Members | 9 | GoverningBodyVotingMembersCnt |
| Independent Voting Member | 7 | IndependentVotingMemberCnt |
| Family Or Business Rln | false | FamilyOrBusinessRlnInd |
| Delegation Of Mgmt Duties | false | DelegationOfMgmtDutiesInd |
| Change To Org Documents | false | ChangeToOrgDocumentsInd |
| Material Diversion Or Misuse | false | MaterialDiversionOrMisuseInd |
| Members Or Stockholders | false | MembersOrStockholdersInd |
| Election Of Board Members | false | ElectionOfBoardMembersInd |
| Decisions Subject To Approva | false | DecisionsSubjectToApprovaInd |
| Minutes Of Governing Body | Yes (true) | MinutesOfGoverningBodyInd |
| Minutes Of Committees | Yes (true) | MinutesOfCommitteesInd |
| Officer Mailing Address | false | OfficerMailingAddressInd |
| Local Chapters | false | LocalChaptersInd |
| Form990 Provided To Gvrn Body | Yes (true) | Form990ProvidedToGvrnBodyInd |
| Conflict Of Interest Policy | Yes (true) | ConflictOfInterestPolicyInd |
| Annual Disclosure Covered Prsn | Yes (true) | AnnualDisclosureCoveredPrsnInd |
| Regular Monitoring Enfrc | Yes (true) | RegularMonitoringEnfrcInd |
| Whistleblower Policy | Yes (true) | WhistleblowerPolicyInd |
| Document Retention Policy | Yes (true) | DocumentRetentionPolicyInd |
| Compensation Process CEO | Yes (true) | CompensationProcessCEOInd |
| Compensation Process Other | Yes (true) | CompensationProcessOtherInd |
| Investment In Joint Venture | false | InvestmentInJointVentureInd |
| States Where Copy Of Return Is Fld | IL | StatesWhereCopyOfReturnIsFldCd |
| Upon Request | Yes (X) | UponRequestInd |
Books In Care Of Detail BooksInCareOfDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | AMY MARSH | PersonNm |
| Phone | 6188478260 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 303 NW 11TH ST | AddressLine1Txt |
| City | FAIRFIELD | CityNm |
| State Abbreviation | IL | StateAbbreviationCd |
| ZIP | 62837 | ZIPCd |
Form990 Part VII Section A Form990PartVIISectionAGrp (17 entries)
| TitleTitleTxt | Average Hours Per WeekAverageHoursPerWeekRt | Individual Trustee Or DirectorIndividualTrusteeOrDirectorInd | Reportable Comp From OrgReportableCompFromOrgAmt | Reportable Comp From Rltd OrgReportableCompFromRltdOrgAmt | Other CompensationOtherCompensationAmt | OfficerOfficerInd | Highest Compensated EmployeeHighestCompensatedEmployeeInd |
|---|---|---|---|---|---|---|---|
| PATRICK MOLT MD | |||||||
| PRESIDENT | 10.00 | Yes (X) | $59,088 | $0 | $0 | ||
| MARTY HEFLIN | |||||||
| TREASURER | 5.00 | Yes (X) | $0 | $0 | $0 | ||
| JAMIE POLLARD | |||||||
| TRUSTEE | 1.00 | Yes (X) | $0 | $0 | $0 | ||
| ANITA POND | |||||||
| TRUSTEE | 1.00 | Yes (X) | $0 | $0 | $0 | ||
| SANDY SIMPSON | |||||||
| TRUSTEE | 1.00 | Yes (X) | $0 | $0 | $0 | ||
| DONNA SULLIVAN | |||||||
| TRUSTEE | 4.00 | Yes (X) | $0 | $0 | $0 | ||
| JOSEPH HUNGERFORD | |||||||
| VICE PRESIDE | 2.00 | Yes (X) | $0 | $0 | $0 | ||
| DOUG WILSON | |||||||
| TRUSTEE | 1.00 | Yes (X) | $0 | $0 | $0 | ||
| JARED VAUGHN | |||||||
| TRUSTEE | 4.00 | Yes (X) | $0 | $0 | $0 | ||
| KATHERINE BUNTING | |||||||
| CEO | 40.00 | $245,742 | $0 | $8,319 | Yes (X) | ||
| ANN IGNAS | |||||||
| CNO | 40.00 | $113,445 | $0 | $7,101 | Yes (X) | ||
| MELODY MORGAN | |||||||
| CFO | 40.00 | $89,760 | $0 | $14,392 | Yes (X) | ||
| WESLEY THOMPSON | |||||||
| PHYSICIAN | 40.00 | $377,746 | $0 | $18,094 | Yes (X) | ||
| CHRIS BALLARD | |||||||
| PHYSICIAN | 40.00 | $289,535 | $0 | $16,566 | Yes (X) | ||
| KYLE KAKAC | |||||||
| PHYSCIAN | 40.00 | $270,671 | $0 | $18,030 | Yes (X) | ||
| ALEXIS KING | |||||||
| CRNA | 40.00 | $199,538 | $0 | $15,594 | Yes (X) | ||
| KIMBERLY KING | |||||||
| CRNA | 40.00 | $197,773 | $0 | $16,681 | Yes (X) | ||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | $1,843,298 | TotalReportableCompFromOrgAmt |
| Total Other Compensation | $114,777 | TotalOtherCompensationAmt |
| Indiv Rcvd Greater Than100 K | 11 | IndivRcvdGreaterThan100KCnt |
| Former Ofcr Employees Listed | false | FormerOfcrEmployeesListedInd |
| Total Comp Greater Than150 K | Yes (true) | TotalCompGreaterThan150KInd |
| Compensation From Other Srcs | false | CompensationFromOtherSrcsInd |
Contractor Compensation ContractorCompensationGrp (5 entries)
| Address Line1ContractorAddress/USAddress/AddressLine1Txt | CityContractorAddress/USAddress/CityNm | State AbbreviationContractorAddress/USAddress/StateAbbreviationCd | ZIPContractorAddress/USAddress/ZIPCd | ServicesServicesDesc | CompensationCompensationAmt |
|---|---|---|---|---|---|
| MURRAY COMPANY | |||||
| 1215 FERN RIDGE PKWY SUITE 213 | ST LOUIS | MO | 63141 | CAFETERIA | $461,061 |
| ARAMARK UNIFORM SERVICES | |||||
| 25259 NETWORK PLACE | CHICAGO | IL | 60673 | LAUNDRY | $443,075 |
| DR RODNEY BEELER | |||||
| 2142 KETTLES HILL COURT | EVANSVILLE | IN | 477258266 | ER PHYSICIAN | $335,788 |
| MICHELLE O'NEILL | |||||
| 10345 WILMINGTON DRIVE | EVANSVILLE | IN | 47577 | ER PHYSICIAN | $331,830 |
| JAMES GRUBER | |||||
| 2025 ST MEINRAD RD | ST MEINRAD | IN | 47577 | ER PHYSICIAN | $291,110 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cntrct Rcvd Greater Than100 K | 17 | CntrctRcvdGreaterThan100KCnt |
| Related Organizations | $44,816 | RelatedOrganizationsAmt |
| Government Grants | $1,255 | GovernmentGrantsAmt |
| All Other Contributions | $218,001 | AllOtherContributionsAmt |
| Total Contributions | $264,072 | TotalContributionsAmt |
Program Service Revenue ProgramServiceRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Desc | NET PATIENT SERVICE REVENUE | Desc |
| Total Revenue Column | $27,788,161 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $27,788,161 | RelatedOrExemptFuncIncomeAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | $27,788,161 | TotalProgramServiceRevenueAmt |
Investment Income InvestmentIncomeGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $179,090 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $179,090 | RelatedOrExemptFuncIncomeAmt |
Gross Rents GrossRentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $227,724 | RealAmt |
Rental Income Or Loss RentalIncomeOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $227,724 | RealAmt |
Net Rental Income Or Loss NetRentalIncomeOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $227,724 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $227,724 | RelatedOrExemptFuncIncomeAmt |
Other Revenue Misc OtherRevenueMiscGrp (3 entries)
| DescDesc | Total Revenue ColumnTotalRevenueColumnAmt | Related Or Exempt Func IncomeRelatedOrExemptFuncIncomeAmt |
|---|---|---|
| MEDICARE EHR REVENUE | $197,971 | $197,971 |
| CAFETERIA SERVICES | $174,507 | $174,507 |
| MISCELLANEOUS | $22,540 | $22,540 |
Miscellaneous Revenue MiscellaneousRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $11,738 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $11,738 | RelatedOrExemptFuncIncomeAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Revenue Total | $406,756 | OtherRevenueTotalAmt |
Total Revenue TotalRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $28,865,803 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $28,601,731 | RelatedOrExemptFuncIncomeAmt |
| 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 | $508,035 | TotalAmt |
| Program Services | $508,035 | ProgramServicesAmt |
Other Salaries And Wages OtherSalariesAndWagesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $11,330,439 | TotalAmt |
| Program Services | $11,330,439 | ProgramServicesAmt |
Pension Plan Contributions PensionPlanContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $138,737 | TotalAmt |
| Program Services | $138,737 | ProgramServicesAmt |
Other Employee Benefits OtherEmployeeBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,925,433 | TotalAmt |
| Program Services | $1,925,433 | ProgramServicesAmt |
Payroll Taxes PayrollTaxesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $788,832 | TotalAmt |
| Program Services | $788,832 | ProgramServicesAmt |
Fees For Services Legal FeesForServicesLegalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $3,794 | TotalAmt |
| Program Services | $3,794 | ProgramServicesAmt |
Fees For Services Accounting FeesForServicesAccountingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $35,700 | TotalAmt |
| Program Services | $35,700 | ProgramServicesAmt |
Fees For Services Other FeesForServicesOtherGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $4,926,005 | TotalAmt |
| Program Services | $4,926,005 | ProgramServicesAmt |
Advertising AdvertisingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $96,054 | TotalAmt |
| Program Services | $96,054 | ProgramServicesAmt |
Office Expenses OfficeExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,605,256 | TotalAmt |
| Program Services | $1,605,256 | ProgramServicesAmt |
Occupancy OccupancyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,153,143 | TotalAmt |
| Program Services | $1,153,143 | ProgramServicesAmt |
Travel TravelGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $186,259 | TotalAmt |
| Program Services | $186,259 | ProgramServicesAmt |
Interest InterestGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $338,047 | TotalAmt |
| Program Services | $338,047 | ProgramServicesAmt |
Depreciation Depletion DepreciationDepletionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,484,828 | TotalAmt |
| Program Services | $1,484,828 | ProgramServicesAmt |
Insurance InsuranceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $343,636 | TotalAmt |
| Program Services | $343,636 | ProgramServicesAmt |
Other Expenses OtherExpensesGrp (4 entries)
| DescDesc | TotalTotalAmt | Program ServicesProgramServicesAmt |
|---|---|---|
| DRUGS | $1,225,255 | $1,225,255 |
| MEDICAL SUPPLIES | $1,155,233 | $1,155,233 |
| REPAIRS AND MAINTENANCE | $581,575 | $581,575 |
| BED AND PROVIDER TAX AMT | $573,999 | $573,999 |
All Other Expenses AllOtherExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $607,869 | TotalAmt |
| Program Services | $607,869 | ProgramServicesAmt |
Total Functional Expenses TotalFunctionalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $29,008,129 | TotalAmt |
| Program Services | $29,008,129 | ProgramServicesAmt |
| Management And General | $0 | ManagementAndGeneralAmt |
| Fundraising | $0 | FundraisingAmt |
Cash Non Interest Bearing CashNonInterestBearingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,744 | BOYAmt |
| EOY | $1,744 | EOYAmt |
Savings And Temp Cash Invst SavingsAndTempCashInvstGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,101,457 | BOYAmt |
| EOY | $1,977,693 | EOYAmt |
Accounts Receivable AccountsReceivableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $5,442,175 | BOYAmt |
| EOY | $5,891,771 | EOYAmt |
Rcvbl From Disqualified Prsn RcvblFromDisqualifiedPrsnGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $167,484 | BOYAmt |
| EOY | $114,004 | EOYAmt |
Oth Notes Loans Receivable Net OthNotesLoansReceivableNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $778,302 | BOYAmt |
| EOY | $904,508 | EOYAmt |
Inventories For Sale Or Use InventoriesForSaleOrUseGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $323,720 | BOYAmt |
| EOY | $376,118 | EOYAmt |
Prepaid Expenses Defrd Charges PrepaidExpensesDefrdChargesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $285,501 | BOYAmt |
| EOY | $769,350 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Bldg Equip Cost Or Other Bss | $37,901,058 | LandBldgEquipCostOrOtherBssAmt |
| Land Bldg Equip Accum Deprec | $22,802,629 | LandBldgEquipAccumDeprecAmt |
Land Bldg Equip Basis Net LandBldgEquipBasisNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $15,953,499 | BOYAmt |
| EOY | $15,098,429 | EOYAmt |
Investments Other Securities InvestmentsOtherSecuritiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $800 | BOYAmt |
| EOY | $800 | EOYAmt |
Other Assets Total OtherAssetsTotalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $626,073 | BOYAmt |
| EOY | $641,317 | EOYAmt |
Total Assets TotalAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $25,680,755 | BOYAmt |
| EOY | $25,775,734 | EOYAmt |
Accounts Payable Accr Expnss AccountsPayableAccrExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,446,397 | BOYAmt |
| EOY | $3,065,062 | EOYAmt |
Deferred Revenue DeferredRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $708,759 | BOYAmt |
| EOY | $511,896 | EOYAmt |
Mortg Notes Pybl Scrd Invst Prop MortgNotesPyblScrdInvstPropGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $7,135,031 | BOYAmt |
| EOY | $6,614,592 | EOYAmt |
Unsecured Notes Loans Payable UnsecuredNotesLoansPayableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $270,181 | BOYAmt |
| EOY | $519,315 | EOYAmt |
Other Liabilities OtherLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $297,222 | BOYAmt |
| EOY | $315,000 | EOYAmt |
Total Liabilities TotalLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $10,857,590 | BOYAmt |
| EOY | $11,025,865 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Organization Follows SFAS117 | Yes (X) | OrganizationFollowsSFAS117Ind |
Unrestricted Net Assets UnrestrictedNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $14,502,030 | BOYAmt |
| EOY | $14,359,704 | EOYAmt |
Temporarily Rstr Net Assets TemporarilyRstrNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $320,566 | BOYAmt |
| EOY | $389,596 | EOYAmt |
Permanently Rstr Net Assets PermanentlyRstrNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $569 | BOYAmt |
| EOY | $569 | EOYAmt |
Total Net Assets Fund Balance TotalNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $14,823,165 | BOYAmt |
| EOY | $14,749,869 | EOYAmt |
Tot Liab Net Assets Fund Balance TotLiabNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $25,680,755 | BOYAmt |
| EOY | $25,775,734 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Reconcilation Revenue Expnss | -$142,326 | ReconcilationRevenueExpnssAmt |
| Other Changes In Net Assets | $69,030 | OtherChangesInNetAssetsAmt |
| Method Of Accounting Accrual | Yes (X) | MethodOfAccountingAccrualInd |
| Accountant Compile Or Review | false | AccountantCompileOrReviewInd |
| FS Audited | Yes (true) | FSAuditedInd |
FS Audited Basis FSAuditedBasisGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Separate Basis Fincl Stmt | Yes (X) | SeparateBasisFinclStmtInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Audit Committee | Yes (true) | AuditCommitteeInd |
| Federal Grant Audit Required | false | FederalGrantAuditRequiredInd |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Hospital | Yes (X) | HospitalInd |
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 | $449,428 | OtherCostOrOtherBasisAmt |
| Book Value | $449,428 | BookValueAmt |
Buildings BuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $20,213,795 | OtherCostOrOtherBasisAmt |
| Depreciation | $9,246,336 | DepreciationAmt |
| Book Value | $10,967,459 | BookValueAmt |
Equipment EquipmentGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $17,010,267 | OtherCostOrOtherBasisAmt |
| Depreciation | $13,518,584 | DepreciationAmt |
| Book Value | $3,491,683 | BookValueAmt |
Other Land Buildings OtherLandBuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $227,568 | OtherCostOrOtherBasisAmt |
| Depreciation | $37,709 | DepreciationAmt |
| Book Value | $189,859 | BookValueAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Land Buildings | $15,098,429 | TotalBookValueLandBuildingsAmt |
Other Liabilities Org OtherLiabilitiesOrgGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Desc | THIRD PARTY REIMBURSEMENT PROGRAMS | Desc |
| Amt | $315,000 | Amt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Liability | $315,000 | TotalLiabilityAmt |
| Footnote Text | Yes (X) | FootnoteTextInd |
| Total Rev Etc Audited Fincl Stmt | $28,934,833 | TotalRevEtcAuditedFinclStmtAmt |
| Other Revenue | $69,030 | OtherRevenueAmt |
| Revenue Not Reported | $69,030 | RevenueNotReportedAmt |
| Revenue Subtotal | $28,865,803 | RevenueSubtotalAmt |
| Total Revenue Per Form990 | $28,865,803 | TotalRevenuePerForm990Amt |
| Tot Expns Etc Audited Fincl Stmt | $29,008,129 | TotExpnsEtcAuditedFinclStmtAmt |
| Expenses Subtotal | $29,008,129 | ExpensesSubtotalAmt |
| Total Expenses Per Form990 | $29,008,129 | TotalExpensesPerForm990Amt |
Supplemental Information Detail SupplementalInformationDetail (2 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| SCHEDULE D, PAGE 3, PART X | THERE WERE NO PENALTIES, INTEREST, OR UNCERTAIN TAX BENEFITS IDENTIFIED AND RECORDED AS A LIABILITY. |
| SCHEDULE D, PAGE 4, PART XI, LINE 2D | CHANGE IN TEMPORARILY RESTRICTED ASSETS 69,030 |
Schedule H IRS990ScheduleH
| Field | Value | IRS element (for citing) |
|---|---|---|
| Financial Assistance Policy | Yes (true) | FinancialAssistancePolicyInd |
| Written Policy | Yes (true) | WrittenPolicyInd |
| FPG Reference Free Care | Yes (true) | FPGReferenceFreeCareInd |
| Percent200 | Yes (X) | Percent200Ind |
| FPG Reference Discounted Care | Yes (true) | FPGReferenceDiscountedCareInd |
| Percent300 | Yes (X) | Percent300Ind |
| Free Care Medically Indigent | Yes (true) | FreeCareMedicallyIndigentInd |
| Financial Assistance Budget | Yes (true) | FinancialAssistanceBudgetInd |
| Expenses Exceed Budget | false | ExpensesExceedBudgetInd |
| Annual Community Bnft Report | false | AnnualCommunityBnftReportInd |
Unreimbursed Medicaid UnreimbursedMedicaidGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $1,921,254 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $573,999 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $1,347,255 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.04640 | TotalExpensePct |
Total Financial Assistance Typ TotalFinancialAssistanceTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $1,921,254 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $573,999 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $1,347,255 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.04640 | TotalExpensePct |
Health Professions Education HealthProfessionsEducationGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $37,745 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $37,745 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00130 | TotalExpensePct |
Total Other Benefits TotalOtherBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $37,745 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $37,745 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00130 | TotalExpensePct |
Total Community Benefits TotalCommunityBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $1,958,999 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $573,999 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $1,385,000 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.04770 | TotalExpensePct |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | Yes (true) | BadDebtExpenseReportedInd |
| Bad Debt Expense | $1,241,912 | BadDebtExpenseAmt |
| Bad Debt Expense Attributable | $310,478 | BadDebtExpenseAttributableAmt |
| Reimbursed By Medicare | $13,327,341 | ReimbursedByMedicareAmt |
| Cost Of Care Reimbursed By Medcr | $14,893,552 | CostOfCareReimbursedByMedcrAmt |
| Medicare Surplus Or Shortfall | -$1,566,211 | MedicareSurplusOrShortfallAmt |
Costing Methodology Used CostingMethodologyUsedGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cost To Charge Ratio | Yes (X) | CostToChargeRatioInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Written Debt Collection Policy | Yes (true) | WrittenDebtCollectionPolicyInd |
| Financial Assistance Prvsn | Yes (true) | FinancialAssistancePrvsnInd |
| Hospital Facilities | 1 | HospitalFacilitiesCnt |
Hospital Facilities HospitalFacilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | FAIRFIELD MEMORIAL HOSPITAL | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 303 NW 11TH ST | AddressLine1Txt |
| City | FAIRFIELD | CityNm |
| State Abbreviation | IL | StateAbbreviationCd |
| ZIP | 62837 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Website Address | WWW.FAIRFIELDMEMORIAL.ORG | WebsiteAddressTxt |
| State License | 320005545 | StateLicenseNum |
| Licensed Hospital | Yes (X) | LicensedHospitalInd |
| General Medical And Surgical | Yes (X) | GeneralMedicalAndSurgicalInd |
| Critical Access Hospital | Yes (X) | CriticalAccessHospitalInd |
| Emergency Room24 Hrs | Yes (X) | EmergencyRoom24HrsInd |
Hospital Fclty Policies Prctc HospitalFcltyPoliciesPrctcGrp
Hospital Facility Name HospitalFacilityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | FAIRFIELD MEMORIAL HOSPITAL | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
| First Licensed CY Or PY | false | FirstLicensedCYOrPYInd |
| Tax Exempt Hospital CY Or PY | false | TaxExemptHospitalCYOrPYInd |
| CHNA Conducted | Yes (true) | CHNAConductedInd |
| Community Definition | Yes (X) | CommunityDefinitionInd |
| Community Demographics | Yes (X) | CommunityDemographicsInd |
| Existing Resources | Yes (X) | ExistingResourcesInd |
| How Data Obtained | Yes (X) | HowDataObtainedInd |
| Community Health Needs | Yes (X) | CommunityHealthNeedsInd |
| Other Health Issues | Yes (X) | OtherHealthIssuesInd |
| Community Hlth Needs Id Process | Yes (X) | CommunityHlthNeedsIdProcessInd |
| Consulting Process | Yes (X) | ConsultingProcessInd |
| Information Gaps | Yes (X) | InformationGapsInd |
| Other | Yes (X) | OtherInd |
| CHNA Conducted | 16 | CHNAConductedYr |
| Take Into Account Others Input | Yes (true) | TakeIntoAccountOthersInputInd |
| CHNA Conducted With Other Fclts | false | CHNAConductedWithOtherFcltsInd |
| CHNA Conducted With Non Fclts | false | CHNAConductedWithNonFcltsInd |
| CHNA Report Widely Available | Yes (true) | CHNAReportWidelyAvailableInd |
| Rpt Available On Own Website | Yes (X) | RptAvailableOnOwnWebsiteInd |
| Own Website URL | WWW.FAIRFIELDMEMORIAL.ORG | OwnWebsiteURLTxt |
| Paper Copy Public Inspection | Yes (X) | PaperCopyPublicInspectionInd |
| Implementation Strategy Adopt | Yes (true) | ImplementationStrategyAdoptInd |
| Implementation Strategy Adpt | 16 | ImplementationStrategyAdptYr |
| Strategy Posted Website | Yes (true) | StrategyPostedWebsiteInd |
| Strategy Website URL | WWW.FAIRFIELDMEMORIAL.ORG | StrategyWebsiteURLTxt |
| Strategy Attached | false | StrategyAttachedInd |
| Organization Incur Excise Tax | false | OrganizationIncurExciseTaxInd |
| Elig Criteria Explained | Yes (true) | EligCriteriaExplainedInd |
| FPG Family Incm Lmt Free Dscnt | Yes (X) | FPGFamilyIncmLmtFreeDscntInd |
| FPG Family Incm Lmt Free Care | 200.000000000000 | FPGFamilyIncmLmtFreeCarePct |
| FPG Family Incm Lmt Dscnt Care | 300.000000000000 | FPGFamilyIncmLmtDscntCarePct |
| Asset Level Criteria | Yes (X) | AssetLevelCriteriaInd |
| Medical Indigency Criteria | Yes (X) | MedicalIndigencyCriteriaInd |
| Insurance Status Criteria | Yes (X) | InsuranceStatusCriteriaInd |
| Explained Basis | Yes (true) | ExplainedBasisInd |
| App Financial Asst Expln | Yes (true) | AppFinancialAsstExplnInd |
| Described Info | Yes (X) | DescribedInfoInd |
| Described Suprt Doc | Yes (X) | DescribedSuprtDocInd |
| Provided Hospital Contact | Yes (X) | ProvidedHospitalContactInd |
| Provided Nonprofit Contact | Yes (X) | ProvidedNonprofitContactInd |
| Includes Publicity Measures | Yes (true) | IncludesPublicityMeasuresInd |
| FAP App Available On Website | Yes (X) | FAPAppAvailableOnWebsiteInd |
| FAP App Available On Website URL | WWWFAIRFIELDMEMORIALORG | FAPAppAvailableOnWebsiteURLTxt |
| FAP Avlbl On Request No Charge | Yes (X) | FAPAvlblOnRequestNoChargeInd |
| FAP App Avlbl On Request No Chrg | Yes (X) | FAPAppAvlblOnRequestNoChrgInd |
| FAP Sum Avlbl On Request No Chrg | Yes (X) | FAPSumAvlblOnRequestNoChrgInd |
| FAP Notice Displayed | Yes (X) | FAPNoticeDisplayedInd |
| Communtity Notified FAP | Yes (X) | CommuntityNotifiedFAPInd |
| Other Publicity | Yes (X) | OtherPublicityInd |
| FAP Actions On Nonpayment | Yes (true) | FAPActionsOnNonpaymentInd |
| Permit Report To Credit Agency | Yes (X) | PermitReportToCreditAgencyInd |
| Permit Legal Judicial Process | Yes (X) | PermitLegalJudicialProcessInd |
| Collection Activities | Yes (true) | CollectionActivitiesInd |
| Reporting To Credit Agency | Yes (X) | ReportingToCreditAgencyInd |
| Engaged Legal Judicial Process | Yes (X) | EngagedLegalJudicialProcessInd |
| FAP Notified Upon Admission | Yes (X) | FAPNotifiedUponAdmissionInd |
| FAP Notified Before Discharge | Yes (X) | FAPNotifiedBeforeDischargeInd |
| FAP Notified All Patients | Yes (X) | FAPNotifiedAllPatientsInd |
| Documented Elig Determination | Yes (X) | DocumentedEligDeterminationInd |
| Nondis Emergency Care Policy | Yes (true) | NondisEmergencyCarePolicyInd |
| Other Method Used | Yes (X) | OtherMethodUsedInd |
| Amounts Generally Billed | false | AmountsGenerallyBilledInd |
| Gross Charges | false | GrossChargesInd |
Supplemental Information SupplementalInformationGrp (4 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| FACILITY 1, FAIRFIELD MEMORIAL HOSPITAL - PART V, LINE 5 | THE HOSPITAL TOOK INTO ACCOUNT INPUT FROM PERSONS WHO REPRESENT THE BROAD INTERESTS OF THE COMMUNITY SERVED BY THE HOSPITAL, INCLUDING THOSE WITH SPECIAL KNOWLEDGE OF, OR EXPERTISE IN PUBLIC HEALTH (LOCAL, REGIONAL, STATE AND/OR TRIBAL). MEMBERS OF MEDICALLY UNDERSERVED, LOW-INCOME, AND MINORITY POPULATIONS SERVED BY THE HOSPITAL OR INDIVIDUALS OR ORGANIZATIONS REPRESENTING THE INTERESTS OF SUCH POPULATIONS ALSO PROVIDED INPUT. THE MEDICALLY UNDERSERVED ARE MEMBERS OF A POPULATION WHO EXPERIENCE HEALTH DISPARITIES, ARE AT-RISK OF NOT RECEIVING ADEQUATE MEDICAL CARE AS A RESULT OF BEING UNINSURED OR UNDERINSURED, AND/OR EXPERIENCING BARRIERS TO HEALTHCARE DUE TO SOCIOECONOMIC FACTORS SUCH AS GEOGRAPHIC, LANGUAGE, FINANCIAL, ETC. MEMBERS OF THE CHNA STEERING COMMITTEE, THOSE WHO BOTH PARTICIPATED IN FOCUS GROUPS AND THE NEEDS IDENTIFICATION AND PRIORITIZATION PROCESS, WERE CHOSEN BASED ON THEIR UNIQUE EXPERTISE AND EXPERIENCE, INFORMED PERSPECTIVES, AND INVOLVEMENT WITH THE COMMUNITY. THE CHNA STEERING COMMITTEE MEMBERS INCLUDED: CHNA STEERING COMMITTEE MEMBER AREAS OF EXPERTISE: -DIRECTOR, WAYNE COUNTY HEALTH DEPARTMENT -DIRECTOR, THERAPY SERVICES, FAIRFIELD MEMORIAL HOSPITAL -PHARMACIST, FAIRFIELD MEMORIAL HOSPITAL -CEO, FAIRFIELD MEMORIAL HOSPITAL OTHERS PROVIDING INPUT INCLUDED THROUGH THE FOCUS GROUPS INCLUDED: -LOCAL SCHOOL ADMINISTRATOR -SHERIFF, WAYNE COUNTY -BOARD MEMBER, HOUSING AUTHORITY -LOCAL SURGEON -ADMINISTRATOR, WAY-FAIR REHAB |
| FACILITY 1, FAIRFIELD MEMORIAL HOSPITAL - PART V, LINE 11 | PROCESS BY WHICH NEEDS WILL BE ADDRESSED: 1. MENTAL HEALTH THE GROUP IDENTIFIED ACCESS TO CARE ISSUES FOR PERSONS OF ALL AGES WITH BEHAVIORAL HEALTHCARE NEEDS. THE AREA IS EXPERIENCING A SHORTAGE OF PSYCHIATRISTS AND COUNSELORS WHICH IS IMPACTING ALL POTENTIAL PATIENTS AND PARTICULARLY, MEDICAID PATIENTS AND YOUTH. THE FINDINGS REFLECTED THE FOCUS GROUPS CONCERNS OF IDENTIFICATION OF THE NEED FOR COUNSELING FOR YOUTH ON ISSUES OF ANGER MANAGEMENT AND FAMILY ISSUES AND THE NEED TO ADDRESS STRESS AND RELATED ISSUES FOR THOSE FACING FINANCIAL CHANGE AND CHALLENGES. THE GROUP ALSO IDENTIFIED THE NEED FOR INCREASED LOCAL SUBSTANCE ABUSE PREVENTION AND ACCESS TO SERVICES FOR REHABILITATION AND RECOVERY. ACTIONS THE HOSPITAL INTENDS TO TAKE TO ADDRESS THE HEALTH NEED: EXPLORE A SECOND FULL TIME MENTAL HEALTH COUNSELOR PARTNER WITH LOCAL COURTS TO CREATE A STRATEGIC REFERRAL PROGRAM WITHOUT REGARD TO ABILITY TO PAY DEVELOP TELE-HEALTH FOR PSYCHIATRY DEVELOP TELE-HEALTH PHARMACY FOR CONSULTATION WITH MENTAL HEALTH MEDICATION SUB-SPECIALTIES EDUCATE THE COMMUNITY ABOUT MENTAL HEALTH ISSUES AND AVAILABLE MENTAL HEALTH SERVICES FOR ALL AGES DEVELOP LUNCHTIME GRAB-AND-GO PROGRAMS FOR PSYCH-EDUCATION ON TOPICS OF LOCAL INTEREST FOR YOUTH AND ADULTS, INCLUDING STRESS AND ANGER MANAGEMENT DEVELOP ONE MEANS OF MEASURING NEW PERSONS REACHED WITH SERVICES. ANTICIPATED IMPACT OF THESE ACTIONS: INCREASED ACCESS TO MENTAL HEALTH SERVICES FOR ALL AGES AND INCOME LEVELS REDUCED STRESS IMPROVED COPING MECHANISMS THAT MAY IMPACT SUBSTANCE ABUSE, ACTING OUT, AND OTHER ISSUES PROGRAMS AND RESOURCES THE HOSPITAL PLANS TO COMMIT TO ADDRESS THE HEALTH NEED: ADMINISTRATION DIRECTOR OF THERAPY SERVICES DIRECTOR OF PHYSICIAN SERVICES PLANNED COLLABORATION BETWEEN THE HOSPITAL AND OTHER FACILITIES OR ORGANIZATIONS: SCHOOLS COURTS DEPARTMENT OF CHILDREN AND FAMILY SERVICES FOSTER CARE COUNTY HEALTH DEPARTMENT SHERIFF 2. WELLNESS THE GROUP IDENTIFIED RELATED NEEDS AROUND HEART DISEASE AND DIABETES AND THE UNDERLYING ISSUES OF OBESITY AND NUTRITION AND CATEGORIZED THEM AS WELLNESS NEEDS. IT WAS FELT THAT THERE WAS A NEED FOR INCREASED EDUCATION IN ALL OF THESE AREAS ALONG WITH OPPORTUNITIES FOR RECREATION, EXERCISE, AND HEALTHY FOODS AND LIFESTYLES. SPECIFIC NEEDS WERE SEEN AS ADDRESSING NUTRITION NEEDS FOR YOUTH AND DEVELOPING OPPORTUNITIES FOR RECREATION AND PHYSICAL ACTIVITY. THE GROUP ALSO SAW A NEED FOR TARGETED ADVOCACY TO MAKE EDUCATION, SCREENINGS, AND OTHER RESOURCES AVAILABLE TO SEGMENTS OF THE POPULATION WHERE THEY ARE NEEDED MOST. FINALLY, THE GROUP IDENTIFIED A NEED FOR BETTER ACCESS TO PRIMARY CARE FOR UNDERINSURED AND UNINSURED. ACTIONS THE HOSPITAL INTENDS TO TAKE TO ADDRESS THE HEALTH NEED: CONTINUE THE NEW CARE COORDINATION PROGRAM FOR MEDICARE FOR ENCOURAGEMENT OF PHYSICAL ACTIVITY PARTNER WITH KINGDOM KIDS TO PROVIDE DIETARY EDUCATION TO FAMILIES AND FUNDS TO SUPPORT HEALTHY MEALS AND FOOD FOR YOUTH CONTINUE PARTNERSHIP WITH KIDS IN MOTION PROGRAM CONTINUE AND EXPAND HEALTH FAIRS FOR SCREENINGS EXPAND PERIODIC REDUCED-COST LAB TESTS, INCLUDING FREE MAMMOGRAPHY AND COLON SCREENINGS DEVELOP EDUCATION PROGRAM ABOUT CHRONIC ILLNESS AND THE NEED FOR PHYSICAL ACTIVITY, HEALTHY DIETS, AND SCREENINGS CONTINUE CORPORATE HEALTH AND SAFETY EDUCATION AND HEALTH SCREENING PROGRAMS PLANNED COLLABORATION BETWEEN THE HOSPITAL AND OTHER FACILITIES OR ORGANIZATIONS: KINGDOM KIDS KIDS IN MOTION 3. CANCER THE STEERING COMMITTEE IDENTIFIED ISSUES SURROUNDING CANCER AS A SIGNIFICANT LOCAL HEALTH NEED. THE GROUP NOTED HIGH LEVELS OF CANCER GENERALLY IN, AND SURROUNDING, THE SERVICE AREA AND EXPRESSED CONCERN OVER BOTH THE CAUSES OF THE HIGH RATES AND THE AVAILABILITY AND USE OF SERVICES TO ADDRESS CANCER. THE GROUP SAW SPECIFIC NEEDS TO: ATTEMPT TO IDENTIFY THE CAUSES OF CANCER LOCALLY TO PROVIDE INFORMATION ABOUT CANCER AND CANCER PREVENTION, AND SCREENINGS TO THE COMMUNITY ACTIONS THE HOSPITAL INTENDS TO TAKE TO ADDRESS THE HEALTH NEED: START A CANCER SUPPORT GROUP FOR PATIENTS, FAMILY, AND OTHER CAREGIVERS DEVELOP AND PRESENT EDUCATION ABOUT LOCAL CANCER SERVICES ATTEMPT TO EXPAND LOCAL AVAILABILITY OF SERVICES FROM CANCER SPECIALISTS CONTINUE AND EXPAND ACCESS TO SCREENINGS INCLUDING MAMMOGRAPHY, PROSTATE SCREENING, AND COLON SCREENING WHILE FAIRFIELD MEMORIAL HOSPITAL IS NOT POSITIONED TO UNDERTAKE THE RESEARCH NECESSARY TO ATTEMPT TO IDENTIFY THE CAUSES OF CANCER LOCALLY, THE HOSPITAL WILL ATTEMPT TO PARTNER WITH WAYNE COUNTY HEALTH DEPARTMENT AND THE WAYNE COUNTY FARM BUREAU TO IDENTIFY APPROPRIATE RESOURCES TO ATTEMPT TO EXPLAIN THE LOCAL CANCER RATES ANTICIPATED IMPACT OF THESE ACTIONS: EXPANDED SCREENINGS ARE EXPECTED TO LEAD TO EARLIER DETECTION, WHICH MAY LEAD TO DECREASED INCIDENCE OF MORTALITY DUE TO CANCER INCREASED AWARENESS OF CANCER RISKS AND THE NEED FOR SCREENING AND RISK AVOIDANCE WITH YOUNGER AUDIENCES BETTER UNDERSTANDING OF AVAILABLE LOCAL SERVICES IMPROVED PATIENT AND CAREGIVER SUPPORT TO AID IN REDUCING STRESS AND INFORMED DECISION-MAKING PROGRAMS AND RESOURCES THE HOSPITAL PLANS TO COMMIT TO ADDRESS THE HEALTH NEED: ADMINISTRATION CERTIFIED CANCER NURSE ONCOLOGISTS FAMILY PRACTICE PROVIDERS AND ANCILLARY DEPARTMENTS INCLUDING LAB, DIETITIAN, TELE-RADIOLOGY, AND ULTRASONOGRAPHERS PLANNED COLLABORATION BETWEEN THE HOSPITAL AND OTHER FACILITIES OR ORGANIZATIONS: ONCOLOGY GROUP SUSAN G. KOMEN FOUNDATION, RACE FOR THE CURE |
| FACILITY 1, FAIRFIELD MEMORIAL HOSPITAL - PART V, LINE 16I | THE POLICY IS VERBALLY DISCUSSED WITH ALL SELF-PAY PATIENTS. |
| FACILITY 1, FAIRFIELD MEMORIAL HOSPITAL - PART V, LINE 22D | IF A PATIENT APPLIES FOR FINANCIAL ASSISTANCE AND THEY ARE APPROVED THE BILL IS REDUCED TO ZERO. IF THE PATIENT QUALIFIES FOR THE PATIENT DISCOUNT ACT, THEN THE CURRENT ASSIGNED PERCENTAGE IS CHARGED. IF NEITHER APPLY, THEN THE PATIENT IS OFFERED A 20% DISCOUNT IF PAID IN FULL OR AN OFFER OF REASONABLE INTEREST FREE PAYMENTS ARE SET UP. |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
Oth Hlth Care Fclts Not Hospital OthHlthCareFcltsNotHospitalGrp
Oth Hlth Care Fclts OthHlthCareFcltsGrp
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | HORIZON HEALTHCARE | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 213 NW 10TH STREET SUITE A | AddressLine1Txt |
| City | FAIRFIELD | CityNm |
| State Abbreviation | IL | StateAbbreviationCd |
| ZIP | 62837 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | OUTPATIENT PHYSICIAN CLINIC | FacilityTxt |
Supplemental Information Detail SupplementalInformationDetail (10 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| PART I, LINE 7 - COSTING METHODOLOGY EXPLANATION | THE FAIRFIELD MEMORIAL HOSPITAL ASSOCIATION USED A COST TO CHARGE RATIO AS CALCULATED FROM WORKSHEET 2, RATIO OF PATIENT CARE COST-TO-CHARGES, INCLUDED IN THE SCHEDULE H INSTRUCTIONS TO DETERMINE THE AMOUNTS ON LINES 7A AND 7B OF PART I OF SCHEDULE H. |
| PART III, LINE 2 - BAD DEBT EXPENSE METHODOLOGY | THE HOSPITAL CALCULATED BAD DEBT EXPENSE AT COST USING THE COST TO CHARGE RATIO AS CALCULATED USING WORKSHEET 2 OF THE SCHEDULE H INSTRUCTIONS. PATIENT ACCOUNTS ARE WRITTEN OFF TO BAD DEBT ONLY AFTER ALL COLLECTION PROCEDURES HAVE BEEN EXHAUSTED AS OUTLINED IN SCHEDULE H, PART III, LINE 9B. PATIENT ACCOUNTS ARE WRITTEN OFF TO BAD DEBT AFTER ALL DISCOUNTS AND PAYMENTS HAVE BEEN APPLIED. |
| PART III, LINE 3 BAD DEBT EXPENSE, PATIENTS ELIGIBLE FOR ASSISTANCE | BASED ON THE HOSPITAL'S EXPERIENCE WITH ALL ITS PATIENTS, THEY ESTIMATE THAT IT IS LIKELY THAT UP TO ONE FOURTH OF THE PATIENT ACCOUNTS WRITTEN OFF TO BAD DEBTS MAY QUALIFY FOR CHARITY CARE OR OTHER ASSISTANCE BUT CHOSE NOT TO APPLY. THEREFORE, 25% OF THE BAD DEBT EXPENSE WAS INCLUDED ON PART III, LINE 3 AT COST. |
| BAD DEBT EXPENSE FOOTNOTE TO FINANCIAL STATEMENTS | NOTE S - UNCOMPENSATED CARE AND COMMUNITY BENEFIT IN SUPPORT OF ITS MISSION, THE HOSPITAL VOLUNTARILY PROVIDES CARE TO PATIENTS AT LESS THAN ITS ESTABLISHED CHARGES FOR PATIENTS THAT MEET THE HOSPITAL'S CHARITY CARE CRITERIA. BECAUSE THE HOSPITAL DOES NOT PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE, THEY ARE NOT REPORTED IN NET PATIENT SERVICES REVENUE. IN ADDITION, THE HOSPITAL PROVIDES SERVICES TO OTHER MEDICALLY INDIGENT PATIENTS UNDER CERTAIN GOVERNMENT-REIMBURSED PUBLIC AID PROGRAMS. SUCH PROGRAMS PAY PROVIDERS AMOUNTS WHICH ARE LESS THAN ESTABLISHED CHARGES FOR THE SERVICES PROVIDED TO THE RECIPIENTS AND MANY TIMES THE PAYMENTS ARE LESS THAN THE COST OF RENDERING THE SERVICES PROVIDED. THE HOSPITAL'S TOTAL COST OF UNCOMPENSATED CARE RELATING TO THESE SERVICES AND OTHER SERVICES ARE AS FOLLOWS: 2016 2015 CHARITY CARE - 38,910 STATE MEDICAID AND OTHER PUBLIC PROGRAMS 1,347,255 1,081,993 UNCOLLECTIBLE ACCOUNTS 1,379,616 882,248 THE UNCOMPENSATED CARE COST OF STATE MEDICAID AND OTHER PUBLIC AID PROGRAMS IS DETERMINED BY COMPUTING THE COST OF PROVIDING THAT CARE LESS AMOUNTS PAID BY THE PROGRAM. IN ADDITION TO THE ABOVE COST OF UNCOMPENSATED CARE, THE HOSPITAL ALSO COMMITS SIGNIFICANT TIME AND RESOURCES TO ENDEAVORS AND CRITICAL SERVICES WHICH MEET OTHERWISE UNFULFILLED COMMUNITY NEEDS. MANY OF THESE ACTIVITIES ARE SPONSORED WITH KNOWLEDGE THAT THEY WILL NOT BE SELF-SUPPORTING OR FINANCIALLY VIABLE. |
| PART III, LINE 8 - MEDICARE EXPLANATION | UNPAID COST OF MEDICARE REPRESENTS THE COST (DETERMINED USING THE OVERALL COST TO CHARGE RATIO) OF PROVIDING SERVICES TO PRIMARILY ELDERLY BENEFICIARIES OF THE MEDICARE PROGRAM, IN EXCESS OF PAYMENTS FOR THOSE SERVICES. IRS REVENUE RULING 69-545, WHICH ESTABLISHED THE COMMUNITY BENEFIT STANDARD FOR NONPROFIT HOSPITALS, STATES THAT IF A HOSPITAL SERVES PATIENTS WITH GOVERNMENT HEALTH BENEFTIS, INCLUDING MEDICARE, THEN THIS IS AN INDICATION THAT THE HOSPITAL OPERATES TO PROMOTE THE HEALTH OF THE COMMUNITY. THIS IMPLIES THAT TREATING MEDICARE PATIENTS IS A COMMUNITY BENEFIT. |
| PART III, LINE 9B - COLLECTION PRACTICES EXPLANATION | THE FAIRFIELD MEMORIAL HOSPITAL APPLIES ITS COLLECTION PRACTICES EQUALLY TO ALL PATIENTS, BOTH CHARITY CARE ELIGIBLE AND NON-CHARITY CARE PATIENTS. THE PROCEDURES FOR COLLECTION ON PATIENT ACCOUNTS ARE AS FOLLOWS: SELF-PAY ACCOUNTS AND ACCOUNTS WITH BALANCES AFTER INSURANCE ARE SENT A LETTER REQUESTING PAYMENT. IF NO RESPONSE IS RECEIVED WITHIN 35 DAYS, THE ACCOUNT IS TRANSFERRED TO OUR EARLY-OUT DEPARTMENT FOR A FOLLOW-UP STATEMENT/PHONE CALL TO THE PATIENT. THE HOSPITAL OFFERS THE PATIENTS SEVERAL PAYMENT ALTERNATIVES: 1. CASH/CHECK FOR THE FULL AMOUNT 2. MASTERCARD/VISA/DISCOVER 3. SHORT-TERM MONTHLY INSTALLMENTS BASED ON OUTSTANDING BALANCE SPECIAL PAYMENT ARRANGEMENTS CAN BE MADE UPON REQUEST AND COMPLETION OF A CREDIT APPLICATION WHICH WILL BE VERIFIED AND APPROVED BY THE BUSINESS OFFICE DIRECTOR. IF PAYMENT OR SATISFACTORY PAYMENT ARRANGMENTS AS OUTLINED ABOVE ARE NOT MADE, THE ACCOUNT WILL PROCEED THROUGH A COLLECTION PROCESS AS FOLLOWS: DAY 1 - 1ST NOTICE SENT DAY 7-14 - FIRST PHONE CALL IS MADE. AT LEAST ONE PHONE CALL OR NOTICE PER WEEK FOR THE REMAINDER OF THE EARLY-OUT 90 DAY PERIOD DAY 75 - DEMAND NOTICE IS SENT DAY 90 - ACCOUNT IS SENT TO COLLECTIONS ANY ACCOUNT THAT IS SENT TO COLLECTIONS MAY BE TURNED OVER TO AN ATTORNEY AND ANY ADDITIONAL COSTS ASSOCIATED WITH COLLECTIONS WILL BE ADDED TO THE ACCOUNT BALANCE. |
| PART VI, LINE 2 - NEEDS ASSESSMENT | GENERALLY SPEAKING, THE DETERMINATION OF CURRENT AND FUTURE HEALTH CARE NEEDS OF THE COMMUNITY OR COMMUNITIES SERVED BY FAIRFIELD MEMORIAL HOSPITAL IS BASED ON ALL OR A COMBINATION OF THE FOLLOWING FACTORS; EXISTENCE OR NONEXISTENCE OF SERVICES, OPPORTUNITY, SUPPLY, DEMONSTRATED NEED, "VOICE OF THE CUSTOMER", AND /OR COLLABORATIVE EFFORTS WITH OUTSIDE ENTITIES, GOVERMENT AGENCIES, AND OTHER HEALTH CARE PROVIDERS THAT WOULD ENABLE THE FILLING OF A NEED OR ENHANCE AND COMPLIMENT AN ALREADY EXISTING SERVICE. DATA IS GATHERED CONSTANTLY THROUGH BENCHMARKETING, MARKET RESEARCH, CUSTOMER SURVEYS, PHYSCIAN INPUT, AND THROUGH CONSTANT MONITORING OF STATE AND FEDERAL GUIDELINES. THIS INFORMATION IS REVIEWED AND ANALYZED BY THE HOSPITAL'S SENIOR LEADERSHIP AND INCORPORATED INTO STRATEGIC PLANNING PROCESSES. |
| PART VI, LINE 3 - PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE | SIGNS ARE POSTED IN THE FACILITY. THE PATIENT'S BILL INFORMS THEM OF FINANCIAL ASSISTANCE PROGRAM. OUR HOSPITAL WEBSITE HAS A LINK TO THE FINANCIAL ASSISTANCE APPLICATION. SOCIAL SERVICE DEPARTMENT SPEAKS TO INPATIENTS ABOUT THE PROGRAM. |
| PART VI, LINE 4 - COMMUNITY INFORMATION | FAIRFIELD MEMORIAL HOSPITAL SERVES THE POPULATIONS OF WAYNE COUNTY AND THE SURROUNDING COMMUNITIES WITHOUT REGARD TO AGE, GENDER, INCOME , ETHIC ORGIN, INSURANCE COVERAGE, OR ABILITY TO PAY. WAYNE COUNTY IS A RURAL AREA WITH AN ESTIMATED POPULATION OF 16,423. THE MEDIAN HOUSEHOLD INCOME IN 2015 WAS 44,993, WHICH WAS 83% OF ILLINOIS' AVERAGE. THE PERCENTAGE OF INDIVIDUALS BELOW POVERTY LEVEL WAS 12.8%. |
| PART VI, LINE 7 - STATE FILING OF COMMUNITY BENEFIT REPORT | ILLINOIS |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Compensation Committee | Yes (X) | CompensationCommitteeInd |
| Independent Consultant | Yes (X) | IndependentConsultantInd |
| Written Employment Contract | Yes (X) | WrittenEmploymentContractInd |
| Compensation Survey | Yes (X) | CompensationSurveyInd |
| Board Or Committee Approval | Yes (X) | BoardOrCommitteeApprovalInd |
| Severance Payment | false | SeverancePaymentInd |
| Supplemental Nonqual Rtr Plan | false | SupplementalNonqualRtrPlanInd |
| Equity Based Comp Arrngm | false | EquityBasedCompArrngmInd |
| Comp Based On Revenue Of Flng Org | false | CompBasedOnRevenueOfFlngOrgInd |
| Comp Bsd On Rev Related Orgs | false | CompBsdOnRevRelatedOrgsInd |
| Comp Bsd Net Earns Flng Org | false | CompBsdNetEarnsFlngOrgInd |
| Comp Bsd Net Earns Rltd Orgs | false | CompBsdNetEarnsRltdOrgsInd |
| Any Non Fixed Payments | false | AnyNonFixedPaymentsInd |
| Initial Contract Exception | false | InitialContractExceptionInd |
Rltd Org Officer Trst Key Empl RltdOrgOfficerTrstKeyEmplGrp (6 entries)
| TitleTitleTxt | Base Compensation Filing OrgBaseCompensationFilingOrgAmt | Deferred Compensation Flng OrgDeferredCompensationFlngOrgAmt | Nontaxable Benefits Filing OrgNontaxableBenefitsFilingOrgAmt | Total Compensation Filing OrgTotalCompensationFilingOrgAmt |
|---|---|---|---|---|
| KATHERINE BUNTING | ||||
| CEO | $245,742 | $4,769 | $3,550 | $254,061 |
| WESLEY THOMPSON | ||||
| PHYSICIAN | $377,746 | $7,120 | $10,974 | $395,840 |
| CHRIS BALLARD | ||||
| PHYSICIAN | $289,535 | $5,560 | $11,006 | $306,101 |
| KYLE KAKAC | ||||
| PHYSCIAN | $270,671 | $5,331 | $12,699 | $288,701 |
| ALEXIS KING | ||||
| CRNA | $199,538 | $3,905 | $11,689 | $215,132 |
| KIMBERLY KING | ||||
| CRNA | $197,773 | $3,900 | $12,781 | $214,454 |
Schedule L IRS990ScheduleL
Loans Btwn Org Interested Prsn LoansBtwnOrgInterestedPrsnGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | NICOLE FYIE PHYSICIAN | PersonNm |
| Relationship With Org | WIFE OF BOARD MEMBER | RelationshipWithOrgTxt |
| Loan Purpose | MEDICAL SCHOOL LOAN | LoanPurposeTxt |
| Loan From Organization | Yes (X) | LoanFromOrganizationInd |
| Original Principal | $267,400 | OriginalPrincipalAmt |
| Balance Due | $114,004 | BalanceDueAmt |
| Default | false | DefaultInd |
| Board Or Committee Approval | Yes (true) | BoardOrCommitteeApprovalInd |
| Written Agreement | Yes (true) | WrittenAgreementInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Balance Due | $114,004 | TotalBalanceDueAmt |
Bus Tr Involve Interested Prsn BusTrInvolveInterestedPrsnGrp (2 entries)
| Relationship DescriptionRelationshipDescriptionTxt | TransactionTransactionAmt | TransactionTransactionDesc | Sharing Of RevenuesSharingOfRevenuesInd |
|---|---|---|---|
| PATRICK MOLT | |||
| PHYSICIAN | $59,088 | BOARD MEMBER | false |
| NICOLE FYIE | |||
| PHYSICIAN | $267,535 | WIFE OF BOARD MEMBER | false |
Schedule O IRS990ScheduleO
Supplemental Information Detail SupplementalInformationDetail (9 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| FORM 990, PAGE 1, PART I, LINE 6 | VOLUNTEERS ARE PART OF THE HOSPITAL AUXILIARY WHO RUN FUNDRAISERS ON BEHALF OF THE HOSPITAL AND OPERATE THE GIFT SHOP. |
| FORM 990, PAGE 2, PART III, LINE 4A | COMMITMENT TO SERVE ALL MEMBERS OF THE COMMUNITY, FREE CARE AND/OR SUBSIDIZED CARE,CARE PROVIDED TO PERSONS COVERED BY GOVERNMENTAL PROGRAMS AT BELOW COST,AND HEALTH ACTIVITIES AND PROGRAMS TO SUPPORT THE COMMUNITY WILL BE CONSIDERED WHERE THE NEED AND/OR INDIVIDUALS INABILITY TO PAY COEXISTS. THE COMMUNITY BENEFITS CAN BE MEASURED IN MANY WAYS INCLUDING: DIRECT PATIENT CARE, SCREENINGS, EDUCATION, FUNDRAISING, AND COMMUNITY SERVICE EFFORTS OF OUR COLLEAGUES. THE HOSPITAL PROVIDES CARE TO PERSONS COVERED BY GOVERNMENTAL PROGRAMS, PROVIDING SERVICES TO BOTH MEDICARE AND MEDICAID PATIENTS. CHARITY CARE IS ALSO PROVIDED THROUGH THE HOSPITAL'S INTERNAL POLICY. |
| FORM 990, PAGE 6, PART VI, LINE 11B | THE FORM 990 WAS REVIEWED BY THE CFO AND FINANCE COMMITTEE. AFTER THE FINANCE COMMITTEE IT WAS TAKEN TO THE FULL BOARD FOR APPROVAL. |
| FORM 990, PAGE 6, PART VI, LINE 12C | ANNUALLY EACH BOARD MEMBER RECEIVES THE CORPORATE COMPLIANCE POLICY WHICH INCLUDES THE CONFLICT OF INTEREST POLICY WITHIN IT TO REVIEW AND SIGN THAT THEY HAVE READ THE POLICY AND HAVE NO COMFLICTS. ALL SIGNED DOCUMENTS ARE KEPT ON FILE IN ADMINISTRATION OFFICE. |
| FORM 990, PAGE 6, PART VI, LINE 15A | THE CEO'S COMPENSATION PROCESS INVOLVES ALLIANT, THE HOSPITAL'S MANAGEMENT COMPANY, BRINGING EVALUATION TIME SALARY INFORMATION FOR OTHER ALLIANT HOSPITALS WHICH INCLUDE HOSPITAL'S IN THE FOLLOWING STATES: ILLINOIS, KENTUCKY, AND INDIANIA; AS WELL AS SALARY INFORMATION FOR CEO'S FROM OTHER HOSPITAL'S IN RELEVANT SIZE (IN REVENUES) TO FMH. THE SALARY COMPARISON INFORMATION IS PRESENTED TO THE PERSONNEL COMMITTEE OF THE BOARD IN WHICH THEY REVIEW THE INFORMATION AND ESTABLISH THE RATE FOR THE CEO. |
| FORM 990, PAGE 6, PART VI, LINE 15B | MARKET WAGE DATA FOR THE HEALTHCARE INDUSTRY IS REVIEWED FOR COMPARABLE RATES FROM THREE SALARY SURVEYS INCLUDING ALLIANT AS ONE. THE CEO DETERMINES THE AMOUNTS FOR THE OFFICERS. |
| FORM 990, PAGE 6, PART VI, LINE 19 | COPIES OF THE ORGANIZATIONS GOVERING DOCUMENTS, CONFLICT OF INTEREST POLICIES, FINANCIAL STATEMENTS, AND THE FEDERAL FORM 990 TAX RETURN ARE AVAILABLE UPON REQUEST FROM THE ADMINISTRATIVE OFFICES. |
| FORM 990, PART IX, LINE 11G | PROFESSIONAL SERVICES 3,246,460 0 0 PHYSICIANS FEES 1,679,545 0 0 |
| FORM 990, PART XI, LINE 9 | CHANGE IN TEMPORARILY RESTRICTED 69,030 TOTAL 69,030 |
Schedule R IRS990ScheduleR
Id Related Tax Exempt Org IdRelatedTaxExemptOrgGrp
Disregarded Entity Name DisregardedEntityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | FAIRFIELD MEMORIAL HOSPITAL FOUNDAT | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 303 NW 11TH STREET | AddressLine1Txt |
| City | FAIRFIELD | CityNm |
| State Abbreviation | IL | StateAbbreviationCd |
| ZIP | 62837 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 371185754 | EIN |
| Primary Activities | SUPPORT | PrimaryActivitiesTxt |
| Legal Domicile State | IL | LegalDomicileStateCd |
| Exempt Code Section | 501C3 | ExemptCodeSectionTxt |
| Public Charity Status | 11B | PublicCharityStatusTxt |
| Direct Controlling NA | N/A | DirectControllingNACd |
| Controlled Organization | false | ControlledOrganizationInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Receipt Of Int Annts Rnts Rylts | false | ReceiptOfIntAnntsRntsRyltsInd |
| Gift Grnt Or Cap Contri To Oth Org | false | GiftGrntOrCapContriToOthOrgInd |
| Gift Grnt Cap Contri From Oth Org | Yes (true) | GiftGrntCapContriFromOthOrgInd |
| Loans Or Guarantees To Other Org | false | LoansOrGuaranteesToOtherOrgInd |
| Loans Or Guarantees From Oth Org | false | LoansOrGuaranteesFromOthOrgInd |
| Div Related Organization | false | DivRelatedOrganizationInd |
| Asset Sale To Other Org | false | AssetSaleToOtherOrgInd |
| Asset Purchase From Other Org | false | AssetPurchaseFromOtherOrgInd |
| Asset Exchange | false | AssetExchangeInd |
| Rental Of Facilities To Oth Org | false | RentalOfFacilitiesToOthOrgInd |
| Rental Of Fclts From Oth Org | false | RentalOfFcltsFromOthOrgInd |
| Perform Of Services For Oth Org | false | PerformOfServicesForOthOrgInd |
| Perform Of Services By Other Org | false | PerformOfServicesByOtherOrgInd |
| Sharing Of Facilities | false | SharingOfFacilitiesInd |
| Paid Employees Sharing | false | PaidEmployeesSharingInd |
| Reimbursement Paid To Other Org | false | ReimbursementPaidToOtherOrgInd |
| Reimbursement Paid By Other Org | false | ReimbursementPaidByOtherOrgInd |
| Transfer To Other Org | false | TransferToOtherOrgInd |
| Transfer From Other Org | false | TransferFromOtherOrgInd |
Transactions Related Org TransactionsRelatedOrgGrp
Other Organization Name OtherOrganizationName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | FMH FOUNDATION | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Transaction Type | C | TransactionTypeTxt |
| Method Of Amount Determination | ACTUAL CASH RECEIVED | MethodOfAmountDeterminationTxt |