2016-05-16T09:23:32-05:00 2015-06-30 351178661 BLUE & CO LLC 500 N MERIDIAN ST SUITE 200 INDIANAPOLIS IN 46204 990 2014-07-01 350985964 LITTLE COMPANY OF MARY HOSPITAL OF INDIANA INC LITT 8124822345 800 WEST NINTH STREET JASPER IN 47546 RANDALL J RUSSELL VP OF FINANCE & CFO 8129960507 2016-05-16 1 ANGELA N CRAWFORD P00573197 3176334705 2016-05-16 2014 2016-08-17 19:52:53Z MEMORIAL HOSPITAL & HEALTH CARE CTR E KYLE BENNETT 800 WEST NINTH STREET JASPER IN 47546 198743926 0 X WWW.MHHCC.ORG X 1950 IN PROVIDE HEALTH SERVICES CONSISTENT WITH THE NEEDS OF THE COMMUNITY. 15 12 1716 236 147062 86084 348901 1038890 183569987 190252351 1856855 1815720 5333257 4954096 191109000 198061057 257419 320904 0 0 93902695 101757191 0 0 0 88812916 88491387 182973030 190569482 8135970 7491575 236494355 238526688 81874459 79590051 154619896 158936637 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 159431344 320904 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. 159431344 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 1 1 1 0 0 0 0 0 0 0 1 0 1 0 0 0 0 1 1 1 0 0 0 1 201 0 1 1716 1 1 1 0 0 0 0 0 0 0 0 0 X 15 12 1 0 0 0 1 1 1 1 1 0 0 0 1 1 1 1 1 1 1 0 IN X RANDALL RUSSELL 8129960506 800 WEST NINTH STREET JASPER IN 47546 RAYMOND SNOWDEN BOARD CHAIRPERSON 40.00 1.00 X X 546255 0 35745 E KYLE BENNETT PRESIDENT & CEO (APR-JUN) 40.00 1.00 X X 406223 0 36376 ROBERT DISINGER BOARD VICE CHAIRPERSON 30.00 0.00 X X 0 0 0 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 8703 RYAN SHERER MD MEDICAL STAFF PRESIDENT 1.00 0.00 X 24402 0 0 SCOTT BECKMAN MD BOARD MEMBER 1.00 0.00 X 0 0 0 ROBERT EHRHARD MD BOARD MEMBER 1.00 0.00 X 26165 0 0 JIM HUEBNER BOARD MEMBER 1.00 0.00 X 0 0 0 SHERRIL LUEKEN BOARD MEMBER 1.00 0.00 X 0 0 0 SOHAIL QADIR MD BOARD MEMBER 1.00 0.00 X 612664 0 25310 KENNETH SENDELWECK BOARD MEMBER 1.00 1.00 X 0 0 0 JOSEPH STEURER BOARD MEMBER 1.00 0.00 X 0 0 0 MICHAEL UEBELHOR BOARD MEMBER 1.00 0.00 X 0 0 0 SR SHARON ANN WALSH PROVINCE LEADER 1.00 0.00 X 0 0 0 RANDALL J RUSSELL VP FINANCE/CFO 40.00 1.00 X 267430 0 29913 KELLY CLAUSS VP MEDICAL PRACTICE 40.00 0.00 X 60416 0 18125 JOHN DILLON VP AMBULATORY SERVICES 40.00 0.00 X 209434 0 29866 TONYA HEIM VP PATIENT SERVICES 40.00 0.00 X 248383 0 30445 GARY LIGHT VP / CIO 40.00 0.00 X 240076 0 15377 DR KARIM ANWAR PHYSICIAN 40.00 0.00 X 716698 0 33634 DR BRIAN WOEBKENBERG PHYSICIAN 40.00 0.00 X 724792 0 32017 DR GEOFFREY DAY PHYSICIAN 40.00 0.00 X 649028 0 17608 DR MICHAEL RUFF PHYSICIAN 40.00 0.00 X 595090 0 15529 DR STEPHEN O'CONNOR PHYSICIAN 40.00 0.00 X 474850 0 41028 5801906 0 369676 97 0 1 0 MEMORIAL HOSPITAL OUTPATIENT SURGERY CEN 800 WEST NINTH STREET JASPER IN 47546 HEALTH SERVICES 3925687 EMCARE INC 7032 COLLECTION CENTER DR CHICAGO IL 60693 HEALTH SERVICES 1849163 VANTAGE ONCOLOGY TREATMENT 4972 LINCOLN AVE SUITE 100 EVANSVILLE IN 47716 ONCOLOGY SERVICES 916876 SEUFERT CONSTRUCTION INC PO BOX 68 FERDINAND IN 47532 CONSTRUCTION SERVICES 886337 ARUP LABORATORIES PO BOX 27964 SALT LAKE CITY UT 84127 HEALTH SERVICES 780488 46 693653 345237 1038890 NET PATIENT SERVICE REVENUE 900099 190252351 190252351 190252351 846729 846729 195066 329769 -134703 -134703 -134703 1220215 101876 124025 229075 1096190 -127199 968991 968991 OTHER REVENUE 900099 4942625 2617915 888 2323822 MEM LAB OTHER REVENUE 621500 146174 146174 5088799 198061057 192870266 147062 4004839 320904 320904 2182767 1826037 356730 83499641 69853295 13646346 1039891 869942 169949 9827581 8221459 1606122 5207311 4356280 851031 113069 94590 18479 130000 108754 21246 18979015 15877275 3101740 395079 330511 64568 881477 737417 144060 11427652 9560031 1867621 981027 820698 160329 2672728 2235924 436804 12376358 10353690 2022668 1249657 1045426 204231 HOSPITAL SUPPLIES AND D 30650681 25642360 5008321 HAF EXPENSE 4540914 3798929 741985 DUES & SUB. 711312 595084 116228 3382418 2782738 599680 190569482 159431344 31138138 0 49097871 50080374 22553293 24804982 2593396 2506435 2655245 2617358 2487880 2689080 207160039 117114667 87027597 90045372 66077702 63308299 378139 360551 3623232 2114237 236494355 238526688 18573631 19251842 57838487 55915185 771686 655624 4690655 3767400 81874459 79590051 X 154619896 158936637 154619896 158936637 236494355 238526688 X 7491575 -1715049 -1459785 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 2064050 2064050 75885978 33736720 42149258 129210011 83377947 45832064 90045372 THIRD PARTY PAYABLE 3767400 3767400 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, 2015 AND 2014, 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. PART XI, XII, AND XIII THESE SECTIONS ARE NOT REQUIRED AS THE ORGANIZATION IS PART OF A CONSOLIDATED FINANCIAL STATEMENT. THE CONSOLIDATED FINANCIAL STATEMENTS ARE AUDITED BY AN INDEPENDENT ACCOUNTING FIRM AND PREPARED IN ACCORDANCE WITH GENERALLY ACCEPTED ACCOUNTING PRINCIPLES. 1 1 1 X 1 X 1 1 0 1 1 1438452 1438452 0.00750 14705487 13712110 993377 0.00520 16143939 13712110 2431829 0.01270 1512456 1512456 0.00790 1512456 1512456 0.00790 17656395 13712110 3944285 0.02060 107278 107278 0.00060 42510 42510 0.00020 387806 387806 0.00200 46368 46368 0.00020 583962 583962 0.00300 1 9099197 43355674 41930328 1425346 X 1 1 1 1 MEMORIAL HOSPITAL & HEALTH CARE CENTER 800 W 9TH ST JASPER IN 47546 X X X MEMORIAL HOSPITAL & HEALTH CARE CENTER 1 0 0 1 X X X X X X X X X 14 1 0 0 1 X WWW.MHHCC.ORG X 1 14 0 0 0 1 X 200.000000000000 400.000000000000 X X X X X 1 1 1 X 1 0 X X X 1 X 0 1 MEMORIAL HOSPITAL & HEALTH CARE CENTER PART V, SECTION B, LINE 5: THE ASSESSMENT INVOLVED REPRESENTATIVES FROM 45 ORGANIZATIONS AND COMMUNITIES HELPING TO IDENTIFY THE HEALTH NEEDS OF DUBOIS COUNTY. THE COMMITTEE CONDUCTED A SERIES OF FOCUS GROUP MEETINGS AND SURVEYS TO PROVIDE AN OPPORTUNITY AND FORUM FOR COMMUNITY REPRESENTATIVES TO PARTICIPATE IN IDENTIFYING HEALTH NEEDS. MEMORIAL HOSPITAL & HEALTH CARE CENTER PART V, SECTION B, LINE 11: AT THIS TIME, WE HAVE NOT EXPANDED OPTIONS FOR UN- AND UNDERINSURED PATIENTS. WE CONTINUE TO PROVIDE SERVICES AT MEMORIAL FAMILY CARE BASED ON A SLIDING FEE SCHEDULE. ALSO, THE HOSPITAL CONTINUES TO PROVIDE FINANCIAL ASSISTANCE TO ALL PATIENTS BASED ON FAMILY INCOME. WE ARE NOT ACTIVELY RECRUITING A DERMATOLOGIST. MEMORIAL HOSPITAL & HEALTH CARE CENTER PART V, SECTION B, LINE 22D: THE HOSPITAL FACILITY DETERMINED, DURING THE YEAR, THE MAXIMUM AMOUNT THAT CAN BE CHARGED TO FAP-ELIGIBLE INDIVIDUALS FOR EMERGENCY OR OTHER MEDICALLY NECESSARY CARE BY USING THE AVERAGE OF THE HOSPITAL'S TOP THREE (BY VOLUME) NEGOTIATED INSURANCE RATES. MEMORIAL HOSPITAL & HEALTH CARE CENTER PART V, SECTION B, LINE 24: NON-MEDICALLY NECESSARY SERVICES INCLUDING COSMETIC PROCEDURES ARE NOT ELIGIBLE FOR DISCOUNTED CHARGES OR FINANCIAL ASSISTANCE. 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. PART I, LINE 7G: THE ORGANIZATION DOES NOT PROVIDE ANY SUBSIDIZED HEALTH SERVICES ATTRIBUTABLE TO PHYSICIAN CLINICS. PART II, COMMUNITY BUILDING ACTIVITIES: PROGRAMS WERE OFFERED AT LOW OR DISCOUNTED PRICES. SOME SERVICES SUCH AS SCREENING RESULT SESSIONS OR SUPPORT GROUPS WERE OFFERED FREE TO PARTICIPANTS. THE FOLLOWING IS A LIST OF SERVICES PROVIDED THROUGH THE HEALTH AND WELLNESS DEPARTMENT.HEALTH SCREENINGS INCLUDING WEIGHT, BMI, WAIST CIRCUMFERENCE, BLOOD PRESSURE, LIPID PROFILE, CHEMISTRY PANEL, TOBACCO STATUS, GLUCOSE, PSA AND COLON KITS: 6154 PARTICIPATED AT 47 COMPANIES/ORGANIZATIONS WITH MANY HAVING MULTIPLE SITE LOCATIONS. 1185 PSA'S WERE PERFORMED WHICH INCLUDED THE ANNUAL PSA SCREENING FOR MEN 50 AND OLDER AND 508 COLON KITS WERE DISTRIBUTED. 509 BODY FAT ANALYSES AND 202 CARBON MONOXIDE SCREENINGS WERE PERFORMED. 65 NICOTINE SALIVA TESTS WERE CONDUCTED. HEALTH RISK APPRAISALS WERE PROVIDED FOR PARTICIPANTS IN HEALTH SCREENINGS WITH 3169 COMPLETED. 46 PARTCIPATED IN THE FIRST FRIDAY SCREENINGS WHICH CONSISTED OF A LIPID PROFILE AND GLUCOSE TEST FOR A SMALL FEE PLUS FREE CONSULTATION AND PHYSICIAN REFERAL.3376 PARTICIPANTS ATTENDED SCREENING RESULT SESSIONS TO LEARN ABOUT THE IMPORTANCE OF THEIR SCREENING RESULTS AT THE VARIOUS WORK-SITES. THE LOW-COST SCREENING FEE INCLUDES THESE GROUP RESULTS SESSIONS. SMOKING CESSATION PROGRAMS, DISPLAYS, AND PRESENTATIONS WERE PROVIDED FOR THE COMMUNITY AND COMPANY WORK-SITES AT NO COST FOR 1322 PARTICIPANTS. AMERICAN CANCER SOCIETY AND THE INDIANA TOBACCO PREVENTION AND CESSATION COUNCIL ALSO PROVIDED EDUCATION MATERIALS AT NO CHARGE. THE QUIT LINE AND QUIT NOW MATERIALS WERE ALSO PROVIDED AT ALL DISPLAYS. MEMORIAL HOSPITAL PROVIDED STAFF TO PROMOTE AND TEACH THE CLASSES AND PREPARE THE DISPLAYS. TO DATE 7 REFERRALS HAVE BEEN MADE TO THE FREE INDIANA QUIT LINE. 152 FREE CESSATION DVDS WERE DISTRIBUTED TO INPATIENTS THAT WERE TOBACCO USERS AS WELL AS EMPLOYEES AT WORKSITES SPONSORED BY THE SUBSTANCE ABUSE COUNCIL GRANT.2428 APPOINTMENTS WERE MADE AND KEPT FOR HOSPITAL EMPLOYEES AND LOCAL COMPANY PARTICIPANTS PARTICIPATED IN WELLNESS CHECK-INS TO MONITOR BLOOD PRESSURE AND WEIGHT ON A REGULAR BASIS AT THE WORK-SITE THROUGHOUT THE YEAR. 18 PARTICIPANTS WERE TAUGHT ABOUT WEIGHT LOSS MANAGEMENT IN RELATION TO DISEASE PREVENTION THROUGH THE CHOOSE 8 TO LOSE WEIGHT PROGRAM.CANCER EDUCATION INFORMATION AND HEALTH EDUCATION INFORMATION WAS DISTRIBUTED AT NO COST TO PARTICIPANTS AT SCREENINGS AND THROUGH EMPLOYEE WELLNESS PROGRAMS. CERVICAL CANCER, TOBACCO CESSATION INFORMATION HAS BEEN INCLUDED IN ALL SCREENING PACKETS IN 2013 AND HEART HEALTH INFORMATION HAS BEEN INCLUDED IN SCREENING PACKETS IN 2014.NUTRITION AND HEALTH DISPLAYS AND QUIZZES WERE PROVIDED FOR 2080 WORKSITE PARTICIPANTS.THE FERTILITY CARE (NATURAL FAMILY PLANNING) PROGRAM WAS OFFERED FOR COUPLES, WITH 8 COUPLES' SESSIONS PROVIDED FOR A SMALL FEE. PROGRAMS ARE AVAILABLE AT REDUCED RATE FOR THOSE UNABLE TO PAY FOR THE SERVICES. THESE SERVICES ARE NOW BEING OFFERED THROUGH THE PARISH NURSING PROGRAM EFFECTIVE JULY 1, 2014.MEDIC FIRST AID, CPR PROGRAMS, HEARTSAVER FIRST AID, AED, AND BLOOD BORNE PATHOGENS CLASSES, WERE PROVIDED FOR 433 INDUSTRY WORKERS, SCOUT TROUPS, SCHOOLS AND THE GENERAL PUBLIC FOR A FEE.THE LANGE-FUHS CANCER CENTER CONDUCTED THE MAN TO MAN PROGRAM, THE LOOK GOOD, FEEL BETTER PROGRAM, MEN'S GROUP AND WOMEN'S GROUP, AND THE CELEBRATE LIFE PROGRAM TO AREA CANCER PATIENTS AT NO COST.THE BARIATRIC FORUM AND SUPPORT GROUP WERE OFFERED MONTHLY AT NO COST.VARIOUS MEMORIAL HOSPITAL DEPARTMENTS PROVIDED FREE MONTHLY SUPPORT GROUPS FOR FAMILIES WITH ALZHEIMER'S DISEASE AND DEMENTIA, HEART DISEASE, AND PARKISONS DISEASE. THE DIABETES EDUCATION STAFF PROVIDED FREE MONTHLY SUPPORT GROUPS FOR THOSE WITH DIABETES. THE PASTORAL CARE DEPARTMENT PROVIDED TWO 5-WEEK FREE PROGRAMS FOR THOSE SUFFERING WITH GRIEF.SUPERSITTER (BABYSITTING) CLASSES WERE OFFERED FOR A FEE TO 35 YOUTH TO LEARN ABOUT SAFE BABYSITTING PRACTICES. SCHOOL TEEN HEALTH FAIRS AND COMMUNITY HEALTH FAIRS PRESENTED HEALTH INFORMATION AT NO COST TO THE PUBLIC FOR 2606 YOUTH AND ADULTS, TEACHING THEM WAYS TO IMPROVE THEIR HEALTH.2050 PARTICIPANTS ATTENDED WELLNESS CLASSES AND LUNCH AND LEARN PROGRAMS SPONSORED BY THEIR EMPLOYER, INCLUDING MEMORIAL HOSPITAL EMPLOYEES AND OTHER COMMUNITY PROGRAMS OFFERED BY THE HOSPITAL. PROGRAMS WERE FREE TO HOSPITAL EMPLOYEES. COMPANIES PAID SMALL FEES FOR PRESENTATIONS.1227 PARTICIPATED IN WEIGHT CHALLENGES AT LOCAL COMPANIES AND AT MEMORIAL HOSPITAL. EMPLOYEES OF MEMORIAL HOSPITAL PARTICIPATED FREE. THIS INCLUDED WEIGH IN AND OUT, NUTRITION HANDOUTS, AND SOME NUTRITION CLASSES.MANY PARTICIPATED IN THE MONTHLY FITNESS CLASSES HELD AT THE HOSPITAL WITH AN AVERAGE OF 10 PEOPLE PER WEEK IN ONE MONTH STEP CLASSES, 31 VISITS IN FIVE MONTHS OF WEEKLY ZUMBA CLASSES, 115 VISTIS IN 10 MONTHS OF WEEKLY CORE CLASSES, 239 VISITS IN 12 MONTHS OF WEEKLY GET FIT 55+ CLASSES, 95 VISITS IN 8 MONTHS OF WEEKLY YOGA CLASSES, 156 VISITS IN 11 MONTHS OF WEEKLY JAZZERCISE CLASSES, 84 VISITS IN 7 MONTHS OF WEEKLY CIRCUIT TRAINING, 532 VISITS IN PER WEEK IN CORPORATE FIT IT IN CLASSES, 41 PER WEEK IN OTHER CORPORATE AND ONSITE FITNESS CLASSES, 35 VISITS IN 7 MONTHS OF WEEKLY YOGA YOUR WAY CLASSES, 50 VISITS IN 7 MONTHS OF WEEKLY SHAPE IT UP CLASSES, 51 VISITS IN 4 MONTHS OF WEEKLY FIT MANIA CLASSES, 19 PEOPLE PARTICIPATED IN THE MONTH-LONG BOOT CAMP PROGRAM, AND 107 VISITS IN 9 MONTHS OF WEEKLY STRENGTH AND ENDURANCE CLASSES. FITNESS CLASS OFFERINGS VARIED EACH MONTH AND WERE FREE FOR HOSPITAL EMPLOYEES AND A LOW COST FOR THE COMMUNITY. PARTICIPANTS RECEIVED ONE FREE CLASS FOR EVERY 8 SESSIONS ATTENDED. 53 PARTICIPATED IN FREE FITNESS DEMONSTRATIONS. FREE CLASS COUPONS WERE DISTRIBUTED AT THE SENIOR EVENT IN DUBOIS COUNTY.301 WELLNESS PACKETS AND 37 FITNESS LOGS WERE COMPLETED BY PARTICIPANTS AT THE WORKSITES.AN AVERAGE OF 63 HOURS PER MONTH WAS RECORDED IN VOLUNTEER TIME DONATED TO ASSIST THE DEPARTMENT IN PROVIDING SERVICES FOR THE COMMUNITY.80 HOURS OF TIME WERE SPENT AT COMMUNITY AND HOSPITAL COMMITTEES AND AGENCY MEETINGS TO BETTER THE HEALTH OF OUR COMMUNITY SUCH AS THE SENRIOR PARTNERSHIP, CANCER COMMITTEE, TIE TEAM, LEADESHIP DEVELOPMENT TEAM, SUBSTANCE ABUSE COUNCIL AND OTHER HOSPITAL COMMITTEES.111 PARTICIPATED IN FREE BLOOD PRESSURE CHECKS.148 WERE CONTACTED AND REFERRED TO A PHYSICIAN FOR THEIR SCREENING RESULTS THAT WERE EXTREMELY ELEVATED.45 PEOPLE ATTENDED TWO FREE WELLNET MEETINGS THAT EDUCATED WELLNESS LEADERS IN THE COMMUNITY ABOUT WELLNESS PLANNING.THE COMMUNITY TRANSFORMATION GRANT FROM WELBORN BAPTIST FOUNDATION PROVIDES STAFF HOURS TO ADDRESS ISSUES OF REDUCING CHRONIC DISEASE IN THE COUNTY. IN-KIND CONTRIBUTIONS INCLUDE COMPUTER AND OFFICE SPACE ALONG WITH PAPER AND OFFICE SUPPLIES, POSTAGE, AND REFRESHMENTS FOR MEETINGS. 25 COMPANIES ATTENDED MULTIPLE CORPORATE CHAMPION MEETINGS TO LEARN ABOUT HEALTH TOPICS AND WAYS TO IMRPOVE THE HEALTH CULTURE AND POLICIES AT THEIR WORKSITES. TWELVE COMPANIES REACHED GOOD, BETTER, OR BEST TARGETS FOR THEIR COMPANY WELLNESS INITIATIVES. MANY BLOOD PRESSURE CHECKS WERE CONDUCTED WITH THE MILLION HEARTS DISPLAYS TO GENERATE HEALTH AWARENESS AT SIX COMPANIES. UNDER HEALTHY LIVING ACTIVITIES, 21 COMMUNITY 5K EVENTS WERE SENT TO THOSE ON THE CHAMPIONS LIST SINCE MAY 2014. EIGHT COMPANIES RECEIVED THE AMERICAN HEART ASSOCIATION FIT-FRIENDLY AWARD AFTER PROMOTION OF FITNESS AT THE CORPORATE CHAMPION MEETINGS. 47 COMPANIES RECEIVED FIT FRIENDLY TIPS OF THE MONTH FOR FREE. WE INCREASED FROM 9 PROVIDERS TO 66 QUITLINE PREFERRED PROVIDERS IN THE COUNTY. PART II AS A RESULT OF WELLNESS SERVICES, OTHER SUCCESSES INCLUDED INDIVIDUALS REDUCED OR ELIMINATED THE NEED FOR BLOOD PRESSURE MEDICINE, FOUND AND HAD APPOINTMENTS WITH A PHYSICIAN, GOT DIAGNOSED AND TREATED FOR HYPERTENSION, HIGH CHOLESTEROL, AND DIABETES. CHRONIC DISEASE PREVENTION IS A KEY OUTCOME OF MANY OF THE WELLNESS SERVICES. PART III, LINE 4: SECTION A. FOOTNOTE TO ORGANIZATION'S FINANCIAL STATEMENTS THAT DESCRIBES BAD DEBT EXPENSE: SEE PAGE 9 OF THE AUDITED FINANCIAL STATEMENTS FOOTNOTE 1 FOR FOOTNOTE "PATIENT ACCOUNTS RECEIVABLE, ESTIMATED THIRD-PARTY PAYROL SETTLEMENT AND NET PATIENT SERVICE REVENUE"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 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, 2015: 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 THROUGH THE USE OF HOSPITAL COMMITTEES DEVELOPING STRATEGIC PLANS FOR THE HOSPITAL TO PROVIDE QUALITY CARE TO THE COMMUNITY MEMBERS. PART VI, LINE 3: PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE:IF DURING PATIENT FINANCIAL SERVICES' FINANCIAL COUNSELING OR COLLECTION PROCESS, IT APPEARS THAT AN INDIVIDUAL MAY NOT HAVE THE FINANCIAL RESOURCES TO PAY FOR SERVICES NOT COVERED BY A THIRD PARTY PAYOR, THEN A FINANCIAL DISCLOSURE FORM SHOULD BE COMPLETED BY THE PATIENT. IN ADDITION, OTHER MEMBERS OF THE HOSPITAL STAFF MAY IDENTIFY INDIVIDUALS WHO MAY QUALIFY FOR CHARITY CARE. THE INFORMATION IS FORWARDED TO THE PATIENT FINANCIAL SERVICES DEPARTMENT. 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. IN ADDITION THE HOSPITAL HAS ANNOUNCED A NEW PAYMENT PLAN WHICH ALLOWS PATIENTS TO PAY FOR THEIR HOSPITAL SERVICES AT 0% INTEREST OVER A 25-MONTH PERIOD. REGARDLESS OF INSURANCE COVERAGE, CREDIT HISTORY OR EMPLOYMENT, THE HOSPITAL WILL REFER PATIENTS AUTOMATICALLY TO THE CAREPAYMENT OPTION IF THEY HAVE A BALANCE ON THEIR HOSPITAL ACCOUNT TWO MONTHS AFTER RECEIVING THEIR FIRST STATEMENT. THROUGH A PRE-APPROVED APPLICATION PROCESS, THE PATIENT WILL RECEIVE A 0% INTEREST HOSPITAL-SPONSORED LOYALTY CARD WITH A MINIMUM OF 4% OF THE BALANCE OR $25. 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 INCLUDING MORE THAN 7,700 INPATIENTS AND 230,000 OUTPATIENTS. 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 1 STUDENT LOAN BUY BACK PROGRAM TO OFFSET EDUCATIONAL EXPENSES FOR CRITICALLY 34 51496 TUITION REIMBURSEMENT PROGRAM FOR THE COST OF TUITION AND BOOKS. 73 259091 SCHOLARSHIP PROGRAM TO ASSIST STAFF MEMBERS PURSUING AN UNDERGRADUATE DEGREE TO WORK IN DEFINED CRITICAL SHORTAGE AREAS. 9 10317 PART I, LINE 2: FOR THE STUDENT LOAN BUY-BACK PROGRAM APPLICATIONS ARE SUBMITTED TO THE HUMAN RESOURCE DEPARTMENT; AND REVIEWED FOR DENIAL OR APPROVAL. FOR THE TUITION REIMBURSMENT PROGRAM APPLICATIONS MUST BE APPROVED BY THE DIRECTORS IN CHARGE OF THE EMPLOYEE BEFORE SUBMITTING TO HUMAN RESOURCE DEPARTMENT FOR APPROVAL. IN ADDITION GRADES MUST BE SUBMITTED TO THE HUMAN RESOURCE DEPARTMENT FOR GRADE VERIFICATION. FOR THE SCHOLARSHIP PROGRAM THE SCHOLARSHIP COMMITTEE EXERCISES AUTHORITY IN THE SELECTION PROCESS AND RECIPIENTS MUST RE-APPLY EACH SEMESTER. PART III, ELIGIBILITY AND PROCEDURES FOR STUDENT LOAN BUY-BACK PROGRAM - POLICY STATEMENT: MEMORIAL HOSPITAL AND HEALTH CARE CENTER STRIVES TO BE PROACTIVE IN RECRUITING, ASSISTING, AND ENCOURAGING QUALIFIED INDIVIDUALS TO ENTER INTO CRITICALLY NEEDED HEALTH CARE FIELDS. THIS PROGRAM WAS DESIGNED TO OFFSET EDUCATIONAL EXPENSES BY REIMBURSING APPROVED MONTHLY STUDENT LOAN OBLIGATIONS IN TRADE FOR TIME WORKED AT MEMORIAL HOSPITAL AND HEALTH CARE CENTER. STUDENT LOAN BUY-BACK PROGRAM - PROCEDURE: 1. THE STUDENT LOAN BUY-BACK BENEFIT IS AVAILABLE TO EMPLOYEES RECRUITED BY MEMORIAL HOSPITAL AND HEALTH CARE CENTER FOR CRITICAL SHORTAGE AREAS WHO HAVE EXISTING LOANS. THIS BENEFIT MAY NOT BE USED IN CONJUNCTION WITH THE TUITION REIMBURSEMENT PROGRAM. 2. THE STUDENT LOAN MONIES MUST BE BORROWED BY THE EMPLOYEE FOR OBTAINING A FORMALIZED DEGREE IN A CRITICAL SHORTAGE AREA AS DEFINED BY THE HOSPITAL. EACH POTENTIAL EMPLOYEE MUST HAVE MADE HIS OR HER OWN ARRANGEMENTS FOR THE STUDENT LOAN FINANCING THROUGH AN APPROPRIATE LENDING INSTITUTION. THE HOSPITAL WILL IN NO WAY BE SIGNATORY OR BE HELD RESPONSIBLE FOR THE FINANCIAL CONTRACT OBTAINED THROUGH A LENDING INSTITUTION. 3. THE APPLICATION TITLED "STUDENT BUY-BACK APPLICATION" FOR QUALIFIED INDIVIDUALS MUST BE COMPLETED AND SUBMITTED TO THE HUMAN RESOURCE DEPARTMENT. IT SHALL BE THE RESPONSIBILITY OF HUMAN RESOURCES TO NOTIFY THE EMPLOYEE OF DENIAL OR APPROVAL. 4. THE ACTIVE LOAN BALANCE AT THE TIME OF APPLICATION WILL BE USED TO CALCULATE STUDENT LOAN BUY-BACK. 5. ELIGIBILITY FOR BUY-BACK PAYMENTS COMMENCES AT THE BEGINNING OF THE MONTH FOLLOWING COMPLETION OF THE 60 DAY INTRODUCTORY PERIOD. EMPLOYEES WITH A PRN STATUS ARE NOT ELIGIBLE TO PARTICIPATE IN THE STUDENT LOAN BUY-BACK PROGRAM. BUY-BACK PAYMENTS CEASE IMMEDIATELY WITH TERMINATION. 6. SHOULD AN EMPLOYEE REDUCE TO LESS THAN FULL TIME STATUS (1.0 FTE) THEN THE EMPLOYEE'S MAXIMUM REIMBURSEMENT WILL BE REDUCED PROPORTIONATELY(I.E. A .8 FTE WILL QUALIFY FOR 80% OF THE ALLOWABLE MONTHLY AND TOTAL REIMBURSEMENT AMOUNT). THE EMPLOYEE WILL BE REQUIRED TO COMPLETE A NEW APPLICATION AT THE TIME OF STATUS CHANGE. 7. IF AN INDIVIDUAL IS GIVEN ANY DISCIPLINARY ACTION, THE LOAN BUY-BACK PAYMENT WILL NOT BE MADE FOR THE MONTH IN WHICH THE DISCIPLINARY ACTION OCCURRED AND CONTINUATION OF THE BENEFIT WILL BE REVIEWED. 8. THE MAXIMUM AMOUNT FOR LOAN BUY-BACK WILL BE $250.00 PER MONTH FOR A TOTAL OF 24 MONTHS. 9. THE CRITICAL SHORTAGE AREAS WILL BE IDENTIFIED BY THE ADMINISTRATIVE STAFF OF MEMORIAL HOSPITAL AND THE HUMAN RESOURCE DEPARTMENT WILL HAVE THE LIST AVAILABLE UPON REQUEST. 10. SHOULD A POSITION BE REMOVED FROM THE CRITICAL SHORTAGE LIST, ANY APPROVED APPLICATION FOR THE STUDENT LOAN BUY-BACK SHALL CONTINUE TO BE VALID AND APPROVED EACH YEAR SO LONG AS ALL OTHER CRITERIA ARE MET. 11. STUDENT LOAN BUY-BACK PAYMENTS WILL BE MADE DIRECTLY TO THE EMPLOYEE. THE EMPLOYEE WILL CONTINUE TO BE RESPONSIBLE FOR THEIR OWN PAYMENTS TO THE LENDING INSTITUTION(S). 12. THE EMPLOYEE IS RESPONSIBLE FOR OBTAINING A LETTER STATING THE PURPOSE OF THE LOAN, AMOUNT OF THE LOAN, THE DATE OF ISSUANCE AND THE SIGNATURE OF THE LOAN OFFICER. TUITION REIMBURSEMENT PROGRAM: TUITION REIMBURSEMENT PROGRAM - POLICY STATEMENT: MEMORIAL HOSPITAL AND HEALTH CARE CENTER STRIVES TO PROVIDE A WORKING ENVIRONMENT DESIGNED TO ATTRACT, REWARD AND RETAIN QUALIFIED PERSONNEL. TUITION REIMBURSEMENT IS DEFINED AS THE COST OF TUITION AND BOOKS ONLY FOR CLASSES TAKEN IN PURSUANCE OF AN UNDERGRADUATE DEGREE AT AN ACCREDITED INSTITUTION OF HIGHER EDUCATION. TUITION REIMBURSEMENT PROGRAM - PROCEDURE: 1. ELIGIBILITY: EMPLOYEES MUST BE EMPLOYED AS A REGULAR EMPLOYEE AUTHORIZED TO WORK WEEKEND OPTION OR AT LEAST 64 HOURS PER PAY PERIOD FOR SIX CONSECUTIVE MONTHS. THE SIX MONTH REQUIREMENT IS WAIVED FOR EMPLOYEES TAKING ACADEMIC COURSES TOWARD A DEGREE FOR A CRITICAL SHORTAGE AREA. IF ACADEMIC COURSES ARE RECOMMENDED BY THE DIRECTOR OR VICE PRESIDENT AT THE TIME OF HIRE, THE EMPLOYEE MAY ENROLL IN THE CLASS BEFORE SIX MONTHS OF EMPLOYMENT IS COMPLETED; HOWEVER, TUITION REIMBURSEMENT MAY NOT BE RECEIVED BEFORE SIX MONTHS OF EMPLOYMENT HAS BEEN COMPLETED. THE PROGRAM OF STUDY MUST: (A) BENEFIT THE HOSPITAL, AND EITHER (B) BE RELATED TO THE EMPLOYEE'S PRESENT JOB, OR (C) ENHANCE THE EMPLOYEE'S POTENTIAL FOR ADVANCEMENT TO A POSITION TO WHICH THE EMPLOYEE CAN REASONABLY BE EXPECTED TO BE PROMOTED WITHIN MEMORIAL HOSPITAL AND HEALTH CARE CENTER. TUITION REIMBURSEMENT WILL BE CONSIDERED FOR GRADUATE COURSES IF THE APPLICABLE VICE PRESIDENT OF MEMORIAL HOSPITAL AND HEALTH CARE CENTER REQUESTS THE EMPLOYEE TO CONTINUE HIS/HER EDUCATION TO MEET JOB REQUIREMENTS OF THE CURRENT JOB, TO MEET QUALIFICATIONS OF A PLANNED PROMOTION OR SERVES A BUSINESS PURPOSE OF THE HOSPITAL. INDIVIDUAL SEMINARS AND WORKSHOPS ARE NOT COVERED UNDER THIS POLICY. CERTIFICATE PROGRAMS ARE ONLY COVERED IF COLLEGE CREDIT AND LETTER GRADES ARE PROVIDED FOR CLASSES TAKEN BY THE EMPLOYEE. THE COURSE(S) MUST BE ATTENDED DURING NON-WORKING HOURS OR DIRECTOR/VICE PRESIDENT APPROVAL IS REQUIRED FOR SCHEDULE CHANGES IF NEEDED TO ATTEND CLASSES. THIS ACCOMMODATION MAY NOT BE POSSIBLE IN SOME AREAS. THE HOSPITAL EXPECTS EACH EMPLOYEE INVOLVED IN THE TUITION REIMBURSEMENT PROGRAM TO CONTINUE TO FUNCTION AT AN ACCEPTABLE LEVEL OF PERFORMANCE. A LETTER GRADE OF C (OR EQUIVALENT) OR BETTER MUST BE OBTAINED FOR UNDERGRADUATE COURSES. A GRADE OF B (OR EQUIVALENT) OR BETTER MUST BE ATTAINED FOR GRADUATE CLASSES. GRADES AND CHECK REQUESTS FOR TUITION REIMBURSEMENT MUST BE RECEIVED BY THE HUMAN RESOURCES DEPARTMENT WITHIN TWO WEEKS AFTER GRADES ARE RECEIVED. 2. BENEFITS - FOR CLASSES TAKEN FOR ALL JOB TITLES THAT ARE NOT LISTED AS CRITICAL SHORTAGE: FULL TIME (72 HOURS OR MORE PER PAY PERIOD) UNDERGRADUATE - 90% WITH A MAXIMUM OF $3,000 GRADUATE - 90% WITH A MAXIMUM OF $5,000 PART TIME (WEEKEND OPTION OR MINIMUM OF 64 HOURS PER PAY PERIOD) UNDERGRADUATE - 70% WITH A MAXIMUM OF $2,000 GRADUATE - 70% WITH A MAXIMUM OF $3,000 3. BENEFITS - FOR CLASSES TAKEN FOR JOB TITLES THAT ARE LISTED AS CRITICAL SHORTAGE: FULL TIME (MINIMUM OF 72 HOURS PER PAY PERIOD) UNDERGRADUATE - 90% WITH A MAXIMUM OF $4,000 PART TIME (WEEKEND OPTION OR MINIMUM OF 64 HOURS PER PAY PERIOD) 70% WITH A MAXIMUM OF $4,000 4. APPLICATION PROCEDURE: EMPLOYEES THAT MEET ELIGIBILITY REQUIREMENTS MUST COMPLETE A TUITION REIMBURSEMENT REQUEST FORM. ALL REQUESTS MUST INCLUDE DIRECTOR RECOMMENDATIONS. THE PRESIDENT AND THE DIRECTOR OF HUMAN RESOURCES HAVE THE AUTHORITY FOR THE FINAL APPROVAL OF EACH INDIVIDUAL REQUEST FOR TUITION REIMBURSEMENT. IN CASES WHERE EMPLOYEES HAVE HAD WRITTEN COUNSELING/DISCIPLINARY ACTION WITHIN THE LAST TWELVE MONTHS, TUITION REIMBURSEMENT MAY NOT BE APPROVED. REQUESTS RECEIVED MAY BE DENIED AND THE EMPLOYEE WILL BE ADVISED TO APPLY FOR THE NEXT CLASS SESSION. AFTER CLASS COMPLETION, VERIFICATION OF A LETTER GRADE (OR EQUIVALENT)FOR EACH CLASS MUST BE SUBMITTED TO THE HUMAN RESOURCES DEPARTMENT WITHIN TWO WEEKS OF RECEIPT OF GRADES. REIMBURSEMENT WILL NOT BE OBTAINED WITHOUT GRADE VERIFICATION. IF AN EMPLOYEE WHO HAS RECEIVED TUITION REIMBURSEMENT TERMINATES EMPLOYMENT AT MEMORIAL HOSPITAL (VOLUNTARY OR INVOLUNTARY) OR IF AN EMPLOYEE REDUCES EMPLOYMENT STATUS TO BELOW .6 FTE ALL TUITION REIMBURSEMENT RECEIVED WITHIN THE LAST 24 MONTHS PRIOR TO DATE OF TERMINATION OR STATUS REDUCTION WILL BE REPAID TO MEMORIAL HOSPITAL AND HEALTH CARE CENTER. REPAYMENT IS DUE WITHIN 30 DAYS OF TERMINATION DATE OR STATUS REDUCTION. A STATEMENT AGREEING TO THIS ARRANGEMENT WILL BE SIGNED BY EACH EMPLOYEE AT THE TIME APPLICATION IS MADE. SCHOLARSHIP PROGRAM: SCHOLARSHIP PROGRAM - POLICY STATEMENT: IN AN EFFORT TO PROMOTE PERSONAL AND PROFESSIONAL GROWTH OF STAFF, MEMORIAL HOSPITAL AND HEALTH CARE CENTER PROVIDES A SCHOLARSHIP PROGRAM TO ASSIST STAFF MEMBERS PURSUING AN UNDERGRADUATE DEGREE AT AN ACCREDITED INSTITUTION OF HIGHER EDUCATION TO WORK IN DEFINED CRITICAL SHORTAGE AREAS. SCHOLARSHIP PROGRAM - PROCEDURE: 1. ELIGIBILITY: SCHOLARSHIP APPLICANTS MUST BE EMPLOYED BY MEMORIAL HOSPITAL AND HEALTH CARE CENTER PRIOR TO APPLYING FOR THE SCHOLARSHIP. WEEKEND OPTION EMPLOYEES ARE NOT ELIGIBLE TO PARTICIPATE IN THE SCHOLARSHIP PROGRAM. EMPLOYEES WITH WRITTEN COUNSELING/DISCIPLINARY ACTION WITHIN THE LAST TWELVE MONTHS WILL NOT BE ELIGIBLE FOR THE SCHOLARSHIP PROGRAM. THE HOSPITAL EXPECTS EACH EMPLOYEE INVOLVED IN THE SCHOLARSHIP PROGRAM TO CONTINUE TO FUNCTION AT AN ACCEPTABLE LEVEL OF PERFORMANCE. THE PROGRAM OF STUDY MUST BENEFIT SPECIFICALLY DEFINED CRITICAL SHORTAGE AREAS WITHIN THE HOSPITAL, AS DETERMINED BY THE SCHOLARSHIP COMMITTEE. THE NUMBER OF SCHOLARSHIPS FOR CRITICAL SHORTAGE AREAS WILL BE DETERMINED ANNUALLY. EMPLOYEES THAT MEET ELIGIBILITY REQUIREMENTS MUST COMPLETE AN APPLICATION FORM AND SUBMIT IT TO THEIR DEPARTMENT DIRECTOR. DIRECTOR RECOMMENDATIONS MUST ACCOMPANY ALL APPLICATIONS SENT TO THE HUMAN RESOURCES DEPARTMENT. THE SCHOLARSHIP COMMITTEE WILL EXERCISE AUTHORITY IN THE SELECTION PROCESS. MEMBERS OF THIS COMMITTEE INCLUDE THE PRESIDENT/CEO, TWO VICE PRESIDENTS, THE DIRECTOR OF HUMAN RESOURCES, AND A DIRECTOR FROM ALL THREE DIVISIONS. SCHOLARSHIP RECIPIENTS ARE REQUIRED TO MAINTAIN A 0.8 FTE WORK STATUS. BENEFITS WILL BE CONSISTENT WITH EMPLOYEE STATUS. CREDIT HOURS WILL BE APPLIED WEEKLY TOWARDS THE STUDENT'S WEEKLY REQUIRED HOURS. EXAMPLE: A STUDENT WITH NINE CREDIT HOURS WEEKLY WOULD BE REQUIRED TO WORK 23 HOURS PER WEEK AT THE HOSPITAL. IN THIS EXAMPLE, THE STUDENT WOULD WORK 24 HOURS AT THE HOSPITAL, AS STAFFING WILL NOT BE ADJUSTED MID-SHIFT TO RELEASE STUDENTS EARLY FROM THEIR RESPONSIBILITIES. COURSE(S) WILL BE ATTENDED DURING NON-WORKING HOURS IN COORDINATION WITH STUDENT'S DEPARTMENT DIRECTOR WHO WILL SCHEDULE THEIR HOSPITAL HOURS AS NEEDED FOR DEPARTMENTAL COVERAGE, WHILE NOT INTERFERING WITH HOURS OF CLASS. STUDENTS MUST SUPPLY A CLASS SCHEDULE TO THEIR DIRECTOR AS SOON AS AVAILABLE TO ENABLE THE SCHEDULING PROCESS. AFTER CLASS COMPLETION, VERIFICATION OF A LETTER GRADE (OR EQUIVALENT) FOR EACH CLASS MUST BE SUBMITTED TO THE HUMAN RESOURCES DEPARTMENT WITHIN TWO WEEKS OF RECEIPT OF GRADES. A GRADE POINT AVERAGE OF 2.5 OR GREATER MUST BE MAINTAINED TO REMAIN IN GOOD STANDING. IF A STUDENT'S GPA DROPS BELOW 2.5, THE INDIVIDUAL WILL NOT BE ELIGIBLE TO REMAIN IN THE SCHOLARSHIP PROGRAM AND MUST APPLY FOR AN OPEN POSITION IN THE HOSPITAL TO CONTINUE THEIR EMPLOYMENT. SCHOLARSHIP RECIPIENTS MUST RE-APPLY FOR EACH SEMESTER TO VERIFY ELIGIBILITY BASED ON GRADES AND WORK PERFORMANCE. IF A SCHOLARSHIP RECIPIENT TERMINATES EMPLOYMENT AT MEMORIAL HOSPITAL (VOLUNTARY OR INVOLUNTARY), REDUCES EMPLOYMENT STATUS TO BELOW .8 FTE, OR DOES NOT MAINTAIN SATISFACTORY PERFORMANCE, ALL SCHOLARSHIP ASSISTANCE RECEIVED WITH THE LAST 24 MONTHS PRIOR TO DATE OF TERMINATION, STATUS REDUCTION, OR DISCIPLINARY ACTION WILL BE REPAID TO MEMORIAL HOSPITAL AND HEALTH CARE CENTER. RE-PAYMENT IS DUE WITHIN 30 DAYS OF THIS DATE. STATEMENT AGREEING TO THIS ARRANGEMENT WILL BE SIGNED BY EACH EMPLOYEE EACH TIME APPLICATION IS MADE. 2. BENEFITS: SCHOLARSHIP RECIPIENTS WILL BE PAID MINIMUM WAGE PER CREDIT HOUR TO BE APPLIED TO THEIR 0.8 FTE COMMITMENT. NO ADDITIONAL HOURS WILL BE PAID TO COMPLETE HOMEWORK, CLINICAL HOURS, OR SPECIAL ASSIGNMENTS. CORRESPONDENCE COURSES WILL BE PAID AT MINIMUM WAGE PER CREDIT HOUR FOR A MAXIMUM OF 16 WEEKS. THE STUDENT WILL BE PAID AT THEIR REGULAR HOURLY RATE FOR HOURS WORKED IN THE FACILITY. SCHOLARSHIP ASSISTANCE DOES NOT APPLY WHEN SCHOOL IS NOT IN SESSION. SCHOLARSHIP RECIPIENTS ARE ALSO ELIGIBLE TO APPLY FOR TUITION. X X X 1 1 X X X X 0 1 0 0 0 1 0 0 0 RAYMOND SNOWDEN BOARD CHAIRPERSON 546255 0 0 0 0 0 22700 0 13045 0 582000 0 0 0 E KYLE BENNETT PRESIDENT & CEO (APR-JUN) 406223 0 0 0 0 0 22700 0 13676 0 442599 0 0 0 SOHAIL QADIR MD BOARD MEMBER 612664 0 0 0 0 0 10700 0 14610 0 637974 0 0 0 RANDALL J RUSSELL VP FINANCE/CFO 267430 0 0 0 0 0 20977 0 8936 0 297343 0 0 0 JOHN DILLON VP AMBULATORY SERVICES 209434 0 0 0 0 0 20515 0 9351 0 239300 0 0 0 TONYA HEIM VP PATIENT SERVICES 248383 0 0 0 0 0 21008 0 9437 0 278828 0 0 0 GARY LIGHT VP / CIO 240076 0 0 0 0 0 3500 0 11877 0 255453 0 0 0 DR KARIM ANWAR PHYSICIAN 716698 0 0 0 0 0 15200 0 18434 0 750332 0 0 0 DR BRIAN WOEBKENBERG PHYSICIAN 724792 0 0 0 0 0 19993 0 12024 0 756809 0 0 0 DR GEOFFREY DAY PHYSICIAN 649028 0 0 0 0 0 5200 0 12408 0 666636 0 0 0 DR MICHAEL RUFF PHYSICIAN 595090 0 0 0 0 0 3600 0 11929 0 610619 0 0 0 DR STEPHEN O'CONNOR PHYSICIAN 474850 0 0 0 0 0 22700 0 18328 0 515878 0 0 0 PART I, LINE 1A MEMORIAL HOSPITAL HAS AN EXECUTIVE PERQUISITE PROGRAM WHICH INCLUDES REIMBURSEMENT FOR ALLOWABLE APPROVED PERQUISITE EXPENSES. REIMBURSEMENT MADE AS PART OF THE EXECUTIVE PERQUISITE PROGRAM IS REFLECTED ON THE EXECUTIVE'S W-2 FORM. A HOSPITAL AUTHORITY OF THE CITY OF JASPER 351692946 2013-12-01 56585000 SEE PART VI 0 0 0 A 1865000 56585000 782751 48933346 1 0 0 1 A 0 1 1 1 0 0 0 1 A 0 1 0 0 1 0 0 0 1 A 1 PART I, COLUMN (F), DESCRIPTION OF PURPOSE: THE PROCEEDS OF THE SERIES 2013 BONDS WERE USED FOR THE PURPOSE OF REFUNDING THE PREVIOUSLY HELD 2002 BONDS AND THE SERIES 2008 BONDS. IN ADDITION, THE REMAINING PORTION OF THE SERIES 2013 BONDS, AS OF JUNE 30, 2015, ARE BEING HELD FOR THE PURPOSE OF FINANCING A PORTION OF THE COSTS OF CONSTRUCTION, EQUIPPING, AND RENOVATION AND IMPROVEMENT OF CERTAIN FACILITIES INCLUDING: LANGE FUHS CANCER CENTER EXPANSION, ADMINISTRATION RELOCATION, POWER PLAN MOVE, OUTPATIENT REHAB, ENDOSCOPY, DEMOLITION OF POWER PLANT, SKILLED CARING CENTER, AND SNF AREA OFFICE EXPANSION. MATRIX INTEGRATION SEE BELOW 1671449 SEE BELOW 0 SR R CUNNINGHAM SEE BELOW 283869 SEE BELOW 0 MIKE UEBELHOR SEE BELOW 131199 SEE BELOW 0 SCHEDULE L, PART IV, BUSINESS TRANSACTIONS INVOLVING INTERESTED PERSONS: (A) NAME OF PERSON: MATRIX INTEGRATION(B) RELATIONSHIP BETWEEN INTERESTED PERSON AND THE HOSPITAL: COMPANY'S PRESIDENT IS A BOARD MEMBERS OF MEMORIAL HOSPITAL.(D) DESCRIPTION OF TRANSACTION: MATRIX INTEGRATION PROVIDES PROFESSIONAL IT SERVICES TO MEMORIAL HOSPITAL. THE HOSPITAL PAID $1,671,449 FOR SERVICES TO MATRIX INTEGRATION IN THE CURRENT YEAR.(A) NAME OF PERSON: SISTER R. CUNNINGHAM(B) RELATIONSHIP BETWEEN INTERESTED PERSON AND THE HOSPITAL: BOARD MEMBERS OF MEMORIAL HOSPITAL.(D) DESCRIPTION OF TRANSACTION: SISTER RENEE CUNNINGHAM PROVIDES NURSING SERVICES TO THE HOSPITAL AND SERVES AS A BOARD MEMBER. THE HOSPITAL PAYS AMERICAN PROVIDENCE OF LITTLE COMPANY OF MARY SISTERS $283,869 AS A SPONSORSHIP FOR THE SISTER. THE SISTER DOES NOT ACCEPT COMPENSATION AS SHE HAS TAKEN A VOW OF POVERTY. THE AMERICAN PROVIDENCE OF LITTLE COMPANY OF MARY SISTERS IS THE CORPORATE MEMBER FOR THE HOSPITAL. (A) NAME OF PERSON: MIKE UEBELHOR(B) RELATIONSHIP BETWEEN INTERESTED PERSON AND THE HOSPITAL: BOARD MEMBER OF MEMORIAL HOSPITAL AND OWNER OF UEBELHOR DEVELOPMENT.(D) DESCRIPTION OF TRANSACTION: MIKE UEBELHOR IS A PART OWNER OF UEBELHOR DEVELOPMENTS, WHICH IS THE LESSOR OF THE ORGANIZATION'S URGENT CARE BUILDING IN HUNTINGBERG, IN. THE HOSPITAL PAID $131,199 IN LEASE PAYMENTS AND PROPERTY TAX PAYMENTS TO UEBELHOR DEVELOPMENTS IN THE CURRENT YEAR. FORM 990, PART VI, SECTION A, LINE 2 MR. BENNETT, SISTER CUNNINGHAM, MR. DISINGER, MR. RUBINO, MR. RUSSELL, MR. SENDELWECK AND MR. SNOWDEN HAVE A BUSINESS RELATIONSHIP AS THEY ARE ALL BOARD MEMBERS FOR THE MEMORIAL HOSPITAL FOUNDATION. FORM 990, PART VI, SECTION A, LINE 6 THE MEMBERS OF THE CORPORATION ARE THE PROVIDENCE LEADER AND COUNCIL MEMBERS OF THE AMERICAN PROVIDENCE OF LITTLE COMPANY OF MARY SISTERS. 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 MEMBERS: 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 11 THE PROCESS FOR REVIEWING THE FORM 990 INCLUDES A REVIEW BY THE CONTROLLER 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 XI, LINE 9: CHANGE IN PENSION -2,036,406. LOSS ON DISPOSITION OF JV 576,621. 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. BARRETT HEALTHCARE CORP OF SW INDIANA 800 WEST 9TH ST JASPER IN 47546 352039829 HEALTHCARE IN 0 3137045 N/A MEMORIAL HOSPITAL FOUNDATION INC 800 WEST NINTH STREET JASPER IN 47546 351359445 BENEFIT MEMORIAL HOSPITAL & HEALTH CARE CENTER IN 501(C)(3) LINE 11A, I MEMORIAL HOSPITAL AND HEALTH CARE CENTER 0 GENESIS HEALTH ALLIANCE LLC 3700 WASHINGTON AVENUE EVANSVILLE IN 47714 208223181 HEALTH CARE IN N/A 1587 12979 0 0 0.04350 0 0 1 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 MEMORIAL HOSPITAL FOUNDATION INC C 693653 CASH