2015-11-04T15:25:08-06:00 2014-12-31 410746749 CLIFTONLARSONALLEN LLP 114 E EVERETT DIXON IL 61021 990 2014-01-01 361000540 KATHERINE SHAW BETHEA HOSPITAL KATH 8152885531 403 EAST FIRST STREET DIXON IL 61021 DAVID SCHREINER CEO 8152855521 2015-11-02 1 TODD M ETHERIDGE P00233050 8152859300 2014 2016-03-07 17:11:31Z DAVID SCHREINER 403 EAST FIRST STREET DIXON IL 61021 137267106 0 X WWW.KSBHOSPITAL.COM X 1893 IL RESTORE, MAINTAIN & ENHANCE HEALTH BY PROVIDING SUPERIOR CARE REGARDLESS OF ABILITY TO PAY. 11 9 1156 161 10525 -5971 595382 735319 125114193 132456104 600946 575348 3368116 1622744 129678637 135389515 8000 159146 0 0 83737526 82883308 0 0 85844 43732854 51060289 127478380 134102743 2200257 1286772 147008398 140486791 67404785 59532126 79603613 80954665 THE MISSION OF KATHERINE SHAW BETHEA HOSPITAL (KSB) IS TO RESTORE, MAINTAIN, AND ENHANCE HEALTH BY PROVIDING SUPERIOR CARE NOW AND IN THE FUTURE, REGARDLESS OF THE PATIENT'S ABILITY TO PAY. 0 0 110041941 159146 132456104 IN 2014 KATHERINE SHAW BETHEA HOSPITAL (KSB) HAD 14,581 INPATIENT VISITS AND 186,604 OUTPATIENT VISITS. KSB IS COMMITTED TO PROVIDING THE HIGHEST QUALITY OF HEALTHCARE REGARDLESS OF ABILITY TO PAY. KSB SUBSIDIZES THE COST OF TREATING PATIENTS WHO ARE UNABLE TO PAY AND THOSE WHO RECEIVE GOVERNMENT ASSISTANCE WHERE REIMBURSEMENT IS LIMITED. THE COST OF CHARITY CARE, BASED ON THE HOSPITAL'S COST-TO-CHARGE RATIO, PROVIDED BY THE HOSPITAL, WAS $3,156,110 IN 2014.KSB PROVIDES 24-HOUR EMERGENCY MEDICAL SERVICES STAFFED BY FULL-TIME PHYSICIANS. PATIENTS ARE TREATED REGARDLESS OF INSURANCE OR ABILITY PAY. ER VISITS IN 2014 WERE 18,963. 110041941 1 1 0 1 0 0 0 0 0 1 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 1 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 1 1 0 0 1 67 0 1156 1 1 1 0 0 0 0 0 0 0 0 1 0 X 11 9 0 0 0 0 0 1 0 1 1 0 0 1 1 1 1 1 1 1 0 0 IL X TONY EVERS 8152855521 403 EAST FIRST STREET DIXON IL 61021 WILLIAM LEFEVRE CHAIRPERSON 1.00 0.00 X X 0 0 0 COLLEEN HENKEL VICE CHARIPERSON 1.00 0.00 X X 0 0 0 CRAIG CARPENTER SECRETARY 1.00 0.00 X X 0 0 0 DOUG LEE TREASURER 1.00 0.00 X X 0 0 0 RICK CURIA PAST CHAIRPERSON 1.00 0.00 X 0 0 0 JOAN MELZER BOARD MEMBER 1.00 0.00 X 0 0 0 RAY NEISEWANDER III BOARD MEMBER 1.00 0.00 X 0 0 0 KATIE PRATT BOARD MEMBER 1.00 0.00 X 0 0 0 THOMAS SUITS BOARD MEMBER 1.00 0.00 X 0 0 0 JOSEPH WELTY MD BOARD MEMBER 40.00 0.00 X 248167 0 36886 DAVID SCHREINER CEO 40.00 1.00 X X 434892 0 61714 ALPHEUS APPENHEIMER MD CMO 40.00 0.00 X 301883 0 36089 LINDA CLEMEN CNO 40.00 0.00 X 213514 0 41259 DEBRA DIDIER CFO 40.00 0.00 X 218648 0 38551 JULIE MANN CAO 40.00 0.00 X 215361 0 40798 KEVIN MARX CHIEF BUSINESS DEVELOPMENT OFFICER 40.00 0.00 X 219197 0 26888 DARRYL VANDERVORT VP - MD RECRUITING & FUND DVLPMT 40.00 0.00 X 53853 0 3230 SULAIMAN MOHAMMAD MD NEUROLOGIST 40.00 0.00 X 934428 0 43856 MONTHER ELBZOUR MD CARDIOLOGIST 40.00 0.00 X 874504 0 43856 SOHAIL HANIF MD CARDIOLOGIST 40.00 0.00 X 794925 0 41356 TYLER GUNDERSON MD SURGEON 40.00 0.00 X 698938 0 41356 IMRE ALMASSY MD RADIOLOGIST 40.00 0.00 X 664114 0 37287 5872424 0 493126 94 0 1 0 QUAMMEN HEALTHCARE CONSULTANTS 522B BRANDIES CIRCLE MURFREESBORO TN 37128 SOFTWARE CONSULTANTS 1099643 WESTERN LITIGATION SPECIALISTS 9821 KATY FREEWAY SUITE 700 HOUSTON TX 77024 LEGAL CONSULTANTS 668986 COMPHEALTH PO BOX 972651 DALLAS TX 75397 STAFFING 601264 MAGNET SOLUTIONS 2223 BROADWAY SCOTTSBLUFF NE 69361 BILLING SERVICES 593696 MECHANICAL INC PO BOX 690 FREEPORT IL 61032 MECHANICAL ENGINEERS 496487 22 193221 542098 10500 735319 NET PATIENT SERVICE REVENUE 621110 132134394 132134394 SUBSIDIARY EARNINGS 621110 321710 321710 132456104 604449 604449 305868 342497 -36629 -36629 -36629 1505793 200 1524042 11052 -18249 -10852 -29101 -29101 MEANINGFUL USE PAYMENTS 621110 2093835 2093835 CAFETERIA SALES 900099 403904 10525 393379 ALL OTHER REVENUE 900099 -190877 -190877 -647489 -647489 1659373 135389515 132456104 10525 2187567 150146 150146 9000 9000 1905877 843973 1004821 57083 60511518 52854146 7651645 5727 2842036 2444151 395043 2842 14135300 12156358 1964807 14135 3488577 2896777 588039 3761 464099 324869 139230 183888 183888 45000 45000 33742 33742 11701656 5125924 6573436 2296 646911 497996 148915 197379 133874 63505 3569340 2335533 1233807 56854 56854 55885 49445 6440 305997 214578 91419 844155 764382 79773 6276291 3672242 2604049 1613945 973880 640065 PATIENT SUPPLIES 13059277 13057747 1530 BAD DEBT EXPENSE 6978279 6978279 IPA TAX 2586640 2586640 NON PATIENT SUPPLIES 1670729 1459454 211275 770222 455693 314529 134102743 110041941 23974958 85844 4195 4204 15869984 9974931 148126 122266 56538358 55946385 1483858 1369336 4197204 5214022 123124371 74789955 51510738 48334416 3891146 4616563 6129937 6546501 192076 91755 7042776 8266412 147008398 140486791 37955325 27448316 22406684 23817398 7042776 8266412 67404785 59532126 X 79050142 80085070 137554 157119 415917 712476 79603613 80954665 147008398 140486791 1286772 64280 0 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 33742 33742 0 PART II-B, LINE 1: A PORTION OF THE HOSPITAL'S MEMBERSHIP DUES WITH THE ILLINOIS HOSPITAL ASSOCIATION AND THE AMERICAN HOSPITAL ASSOCIATION ARE USED BY THOSE ASSOCIATIONS TO CONDUCT LOBBYING ACTIVITIES ON BEHALF OF ALL MEMBER HOSPITALS. 1266546 306847 1573393 1073194 193352 1266546 25000 1048194 1073194 25000 25000 25000 25000 0.98000 0.02000 0.00000 0 0 2129972 2129972 47494934 25231480 22263454 4800500 2383176 2417324 67250912 47175299 20075613 1448053 1448053 48334416 DEFERRED COMPENSATION 8266412 8266412 DEFERRED COMPENSATION PAYABLE 8266412 8266412 X 127996508 1036483 1036483 126960025 8429490 8429490 135389515 127457961 342497 342497 127115464 6987279 6987279 134102743 PART V, LINE 4: THE PURPOSE OF THE BULK OF THE ENDOWMENT FUND IS TO FUND COMMUNITY WELLNESS PROJECTS FOR THE KSB SERVICE AREA. THE REST OF THE ENDOWMENT, $25,000, WAS ESTABLISHED MANY YEARS AGO AND IS IN AN ACCOUNT WITH OTHER RESTRICTED FUNDS WHICH ALL EARN INTEREST. THE INTEREST ON THIS ENDOWMENT IS INTENDED TO BE USED TO PROVIDE FREE SERVICES TO THE NEEDY. AT THIS TIME, THE BANK GROUPS ALL INTEREST BEARING ACCOUNTS TOGETHER TO DETERMINE INTEREST EARNED AGAINST FEES INCURRED. ANY INTEREST EARNED IS THEN REPORTED IN TOTAL FOR ALL ACCOUNTS ON THE STATEMENT OF REVENUE. THOUGH KSB IS NOT ABLE TO SEPARATELY REPORT THE INTEREST EARNED ON THE ENDOWMENT, THE HOSPITAL HAS SHOWN ON SCHEDULE H THAT THEY PROVIDE MANY FREE SERVICES TO THOSE IN NEED WITH THE FUNDS THEY RECEIVE. PART X, LINE 2: THE HOSPITAL FILES A FORM 990 (RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX) ANNUALLY. WHEN THIS RETURN IS FILED, IT IS HIGHLY CERTAIN THAT SOME POSITIONS TAKEN WOULD BE SUSTAINED UPON EXAMINATION BY THE TAXING AUTHORITIES, WHILE OTHERS ARE SUBJECT TO UNCERTAINTY ABOUT THE MERITS OF THE POSITION TAKEN OR THE AMOUNT OF THE POSITION THAT WOULD ULTIMATELY BE SUSTAINED. EXAMPLES OF TAX POSITIONS INCLUDE SUCH MATTERS AS THE FOLLOWING: THE TAX EXEMPT STATUS OF THE ENTITY AND VARIOUS POSITIONS RELATIVE TO POTENTIAL SOURCES OF UNRELATED BUSINESS TAXABLE INCOME (UBIT). UBIT IS REPORTED ON FORM 990T, AS APPROPRIATE. THE BENEFIT OF A TAX POSITION IS RECOGNIZED IN THE FINANCIAL STATEMENTS IN THE PERIOD DURING WHICH, BASED ON ALL AVAILABLE EVIDENCE, MANAGEMENT BELIEVES THAT IT IS MORE LIKELY THAN NOT THAT THE POSITION WILL BE SUSTAINED UPON EXAMINATION, INCLUDING THE RESOLUTION OF APPEALS OR LITIGATION PROCESSES, IF ANY. TAX POSITIONS ARE NOT OFFSET OR AGGREGATED WITH OTHER POSITIONS. TAX POSITIONS THAT MEET THE "MORE LIKELY THAN NOT" RECOGNITION THRESHOLD ARE MEASURED AS THE LARGEST AMOUNT OF TAX BENEFIT THAT IS MORE THAN 50 PERCENT LIKELY TO BE REALIZED ON SETTLEMENT WITH THE APPLICABLE TAXING AUTHORITY. THE PORTION OF THE BENEFITS ASSOCIATED WITH TAX POSITIONS TAKEN THAT EXCEEDS THE AMOUNT MEASURED AS DESCRIBED ABOVE IS REFLECTED AS A LIABILITY FOR UNRECOGNIZED TAX BENEFITS IN THE ACCOMPANYING STATEMENTS OF FINANCIAL POSITION ALONG WITH ANY ASSOCIATED INTEREST AND PENALTIES THAT WOULD BE PAYABLE TO THE TAXING AUTHORITIES UPON EXAMINATION. PRESENTLY, THERE ARE NO ONGOING INCOME TAX AUDITS OR UNRESOLVED DISPUTES WITH TAX AUTHORITIES THAT THE HOSPITAL CURRENTLY FILES OR HAS FILED WITH. PART XI, LINE 2D - OTHER ADJUSTMENTS: LOSS ON DISPOSAL OF EQUIPMENT 10,852. LOSS ON DEFINED BENEFIT PLAN TERMINATION 647,489. NET ASSETS RELEASED FROM RESTRICTIONS 35,645. RENTAL EXPENSES 342,497. PART XI, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR UNCOLLECTIBLE ACCOUNTS 6,978,279. OTHER INTEREST AND INVESTMENT INCOME 475,694. INCOME ON INVESTMENTS WHOSE USE IS LIMITED 110,506. EQUITY IN EARNINGS OF INVESTEES 321,710. UNRESTRICTED CONTRIBUTION INCOME 10,500. OTHER INCOME 172,707. TEMPORARILY RESTRICTED CONTRIBUTIONS 55,210. PERMANENTLY RESTRICTED CONTRIBUTIONS 295,884. SCHOLARSHIP EXPENSE 9,000. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 342,497. PART XII, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR UNCOLLECTIBLE ACCOUNTS 6,978,279. SCHOLARSHIP EXPENSE 9,000. 1 1 X 1 X 1 X 1 1 0 1 1 3156110 3156110 0.02390 18573712 6449861 12123851 0.09180 21729822 6449861 15279961 0.11570 539163 3699 535464 0.00410 2764422 1447081 1317341 0.01000 311048 232038 79010 0.00060 205618 55472 150146 0.00110 3820251 1738290 2081961 0.01580 25550073 8188151 17361922 0.13150 12750 12750 0.00010 12750 12750 0.00010 1 2000673 200067 24809776 32898575 -8088799 X 1 1 1 1 KATHERINE SHAW BETHEA HOSPITAL 403 E FIRST STREET DIXON IL 61021 WWW.KSBHOSPITAL.COM 2114484 X X X X KATHERINE SHAW BETHEA HOSPITAL 1 0 0 1 X X X X X X X X X 13 1 0 0 1 X WWW.KSBHOSPITAL.COM/CHNA X X 1 13 1 WWW.KSBHOSPITAL.COM/CHNA 0 0 1 X 200.000000000000 300.000000000000 X X X X 1 1 X X X X 1 X X X X X 1 X 0 X X X X 1 X 0 0 KATHERINE SHAW BETHEA HOSPITAL PART V, SECTION B, LINE 5: (1) THE NATIONAL CENTER FOR RURAL HEALTH PROFESSIONALS WORKS TO IMPROVE HEALTHCARE IN RURAL COMMUNITIES THROUGH EDUCATION, EVALUATION AND RESEARCH. THE NATIONAL CENTER FOR RURAL HEALTH PROFESSIONALS IS A MEMBER OF THE STEERING COMMITTE. (2) NORTHWEST ILLINOIS SPECIAL OLYMPICS SERVES DEVELOPMENTALLY DISABLED ADULTS AND CHILDREN. THIS ORGANIZATION WAS PART OF THE STEERING COMMITTEE AND ASSESSMENTS OF THE COMMUNITY. (3) ILLINOIS EMERGENCY MANAGEMENT AGENCY PROVIDES TRAINING AND EDUCATION FOR THE DISASTERS IN NORTHWEST ILLINOIS COUNTIES. THIS ORGANIZATION WAS PART OF THE STEERING COMMITTEE AND PROVIDED DATA TO FACILITATE THE EDUCATION FOR OUR FACILITY TO ASSIST THE UNDERSERVED POPULATION IN OUR SERVICE AREA IN THE EVENT OF AN EMERGENCY. (4) LEE COUNTY HEALTH DEPARTMENT SERVES RURAL LEE COUNTY TO PROTECT THE HEALTH AND SAFETY OF INDIVIDUALS RESIDING IN AND VISITORS TO LEE COUNTY. (5) THE NATIONAL CENTER FOR RURAL HEALTH PROFESSIONALS WORKS TO IMPROVE HEALTHCARE IN RURAL COMMUNITIES THROUGH EDUCATION, EVALUATION AND RESEARCH. (6) KSB HOSPITAL INFORMATION TECHNOLOGICAL SERVICES STRIVES TO PROMOTE HEALTH AND WELLNESS EDUCATION TO THE UNDERSERVED. KSB HOSPITAL TECHNICAL SERVICES COACHES STEERING COMMITTEE ON OPPORTUNITIES TO COMMUNICATE TO THE UNDERSERVED BY SOCIAL MEDIA OR TEXT MESSAGING. (7) KSB HOSPITAL OUTPATIENT WELLLNESS DIETITIAN PROVIDES EDUCATION AND TRAINING TO MEDICAID AND UNINSURED. (8) AMBOY PUBLIC SCHOOL DISTRICT STUDENTS WERE ABLE TO COMMUNICATE, THROUGH A GOOGLE SURVEY, THE WELLNESS NEEDS OF THEIR COMMUNITY. (9) THE DIRECTOR OF THE LINCOLN HIGHWAY HISTORICAL SOCIETY WAS ABLE TO COMMUNICATE THE NEEDS OF FRANKLING GROVE ILLINOIS, ONE OF OUR SERVICE AREAS. THE LINCOLN HIGHWAY HISTORICAL SOCIETY WAS A MEMBER OF A FOCUS GROUP. (10) UNIVERSITY OF ILLINOIS EXTENSION SERVING LEE, CARROLL, AND WHITESIDE COUNTIES WAS A MEMBER OF THE FOCUS GROUP. U OF I EXTENSION'S PROGRAMS ARE RESEARCH-BASED AND PRACTICAL. KATHERINE SHAW BETHEA HOSPITAL PART V, SECTION B, LINE 7D: KATHERINE SHAW BETHEA HOSPITAL IS A 80 BED RURAL ACUTE CARE HOSPITAL. ITS CHNA IS ALSO PROVIDED TO THE PUBLIC THROUGH SOCIAL MEDIA, INCLUDING BUT NOT LIMITED TO FACEBOOK AND TWITTER. KATHERINE SHAW BETHEA HOSPITAL PART V, SECTION B, LINE 11: OUR COMMUNITY'S SIGNIFICANT COMMUNITY HEALTH NEEDS ARE OBESITY EDUCATION AND PREVENTION, TOBACCO USE PREVENTION AND TREATMENT, AND COMMUNITY AWARENESS IMPROVEMENT. OBESITY EDUCATION AND PREVENTION: THE EDUCATIONAL PROGRAM JUMP WITH JILL - A NUTRITIONAL ROCK SHOW - WAS PERFORMED IN 5 SCHOOL DISTRICTS THAT HAVE A MINIMUM OF 50% REDUCED TO FREE LUNCHES. COMMUNITY GARDENS WERE PLACED AT REAGAN MIDDLE SCHOOL, PADS HOMELESS SHELTER AND CAMP REYNOLDSWOOD WITH EDUCATION ON PLANTING, GROWING AND HARVESTING SUSTAINABLE FOOD. FOOD PRESERVATION WILL ALSO BE CONDUCTED IN THE LATE FALL 2015. OPERATION MOVE TO WIN HAS IMPACTED OVER 2,400 FAMILIES WITH A TOTAL WEIGHT LOSS OF 10,081 LBS. OPERATION MOVE TO WIN PROVIDES EDUCATION ON NUTRITION, EXERCISE, HEALTH LIVING, STRESS MANAGEMENT AND BEHAVIOR MODIFICATION. NUTRITIONAL COOKING WITH A DIETITIAN ALONG WITH WALK WITH A DOC AND ULTIMATE FRISBEE WITH OUR PODIATRIC DEPARTMENTS WERE CONDUCTED. PREVENTION & TREATMENT OF TOBACCO USE: A TOBACCO QUITLINE WAS ACTIVATED IN ALL CLINICS AND PHYSICIAN OFFICES. PULMONOLOGY CONDUCTED A FREE FORUM ON E-CIGARETTES AND TOBACCO PREVENTION. A PARTNERSHIP WITH THE DIXON PARK DISTRICT TO PROMOTE TOBACCO FREE PARKS WAS CONDUCTED.IMPROVING COMMUNITY AWARENESS: FREE HEALTH AND WELLNESS EDUCATION WAS PROVIDED BUT NOT LIMITED TO SENIORS, THE MEDICALLY UNDERSERVED, AT RISK POPULATIONS, HOMELESS SHELTER AND FOOD PANTRY VIA HEALTH FAIRS, FLU VACCINE CLINICS, CARDIOLOGY PREVENTION AND WOMEN'S HEALTH EVENTS. ALL PROGRAMING AND EVENTS WERE FREE. SOCIAL MEDIA, LOCAL WEB SITES, MARQUEES, AND PLACES SERVING AT RISK POPULATIONS LIKE PROBATION AND COUNSELING CENTERS WERE INFORMED OF ALL UPCOMING EVENTS AND PROGRAMING THAT WERE FREE OF CHARGE. KATHERINE SHAW BETHEA HOSPITAL PART V, SECTION B, LINE 13B: STATE REGULATIONS ARE CONSIDERED IN DETERMINING ELIGIBILITY FOR FINANCIAL ASSISTANCE. KATHERINE SHAW BETHEA HOSPITAL PART V, SECTION B, LINE 22D: KATHERINE SHAW BETHEA HOSPITAL PERIODICALLY REVIEWS DISCOUNTS PROVIDED TO INSURANCE COMPANIES BY COMPARING ACTUAL COLLECTIONS TO GROSS CHARGES. THE HOSPITAL THEN COMPARES THAT AVERAGE (AMOUNTS GENERALLY BILLED) TO THE DISCOUNT GIVEN TO INDIVIDUALS UNDER ITS FINANCIAL ASSISTANCE POLICY TO ENSURE THAT ALL FAP-ELIGIBLE INDIVIDUALS RECEIVE A DISCOUNT AT LEAST AS LARGE AS THE AMOUNTS GENERALLY BILLED DISCOUNT. PART V, SECTION B, LINE 16 FINANCIAL ASSISTANCE POLICY WEBSITE AVAILABILITY KATHERINE SHAW BETHEA HOSPITAL PART V, SECTION B, LINE 16A WEBSITE: WWW.KSBHOSPITAL.COM/NEW/WP-CONTENT/UPLOADS/2012/05/PFS-BROCHURE.PDF 9 COMMERCE TOWERS 215 EAST FIRST STREET DIXON IL 61021 PHYSICIAN CLINIC TOWN SQUARE CENTER 102 S HENNEPIN AVENUE DIXON IL 61021 PHYSICIAN CLINIC KSB OREGON CLINIC 1307 WASHINGTON OREGON IL 61061 PHYSICIAN CLINIC EDWARDS CLINIC 144 NORTH COURT DIXON IL 61021 PHYSICIAN CLINIC AMBOY CLINIC 305 EAST JOE DRIVE AMBOY IL 61310 PHYSICIAN CLINIC MT MORRIS CLINIC 405 CHARLES AVENUE MT MORRIS IL 61054 PHYSICIAN CLINIC KSB EYE & VISION CARE 511 PALMYRA STREET DIXON IL 61021 PHYSICIAN CLINIC POLO CLINIC 1107 SOUTH DIVISION AVENUE POLO IL 61064 PHYSICIAN CLINIC ASHTON CLINIC 707 S MAIN STREET ASHTON IL 61006 PHYSICIAN CLINIC PART I, LINE 7: IT IS KSB HOSPITAL'S POLICY NOT TO WITHHOLD OR DENY ANY REQUIRED MEDICAL CARE AS A RESULT OF A PATIENTS'S LACK OF THE ABILITY TO PAY. THE COSTING METHODOLOGY USED TO CALCULATE THE AMOUNTS IN THE ABOVE TABLE WAS DERIVED FROM THE 2014 CALCULATED COST TO CHARGE RATION USING THE IRS WORKSHEET 2. PART I, LINE 7G: FOR 2014, SUBSIDIZED HEALTH SERVICES INCLUDED A DIABETIC CLINIC AND EMERGENCY MEDICAL SERVICES. PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 2,000,673. PART II, COMMUNITY BUILDING ACTIVITIES: KSB HOSPITAL STRIVES TO BRING THE BEST INTEGRATED, QUALITY AND COST EFFECTIVE CARE AND INNOVATIVE TECHNOLOGY TO OUR SERVICE AREA. KSB SUPPORTS OTHER LOCAL NON-PROFITS THROUGHT CONTRIBUTIONS OF DOLLARS AND HOURS. WE SUPPORT THE LOCAL ECONOMIC DEVELOPMENT ORGANIZATIONS IN AN EFFORT TO BRING EMPLOYERS AND JOBS TO OUR SERVICE AREA. KSB IS A SUPPORTER OF THE ADOPT-A-ROAD PROGRAM. OUR EMPLOYEES CLEAN UP A STRETCH OF ILLINOIS ROUTE 2 TWICE A YEAR TO HELP IMPROVE AND PRESERVE OUR ENVIRONMENT. KSB SUPPORTS WORKFORCE DEVELOPMENT THROUGHT THE JUNIOR ACHIEVEMENT PROGRAM. HOURS AND DOLLARS ARE DONATED TO THIS PROGRAM. KSB ALSO SUPPORTS HABITAT FOR HUMANITY IN AN EFFORT TO PROVIDE AFFORDABLE HOUSING IN OUR SERVICE AREA. MANY OF OUR EMPLOYEES DONATED THEIR OWN TIME TO THIS ORGANIZATION. KSB HAS SUPPORTED HABITAT FOR HUMANITY WITH CASH DONATIONS. PART III, LINE 2: GROSS CHARGES WRITTEN OFF TO BAD DEBT IN 2014 WERE $6,978,279. WE USED IRS WORKSHEET 2 TO CALCULATE THE COST TO CHARGE RATIO. THIS RATIO WAS USED TO ESTIMATE BAD DEBT AT COST. A PATIENTS'S ACCOUNT IS WRITTEN OFF TO BAD DEBT AFTER 180 DAYS. ANY PATIENT PAYMENTS AND DISCOUNTS ARE DEDUCTED FROM GROSS CHARGES PRIOR TO THE WRITE-OFF. PART III, LINE 3: THIS PORTION OF BAD DEBT IS RELATED TO ACCOUNTS THAT MAY HAVE QUALIFIED FOR THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY. THE METHODOLOGY USED IS BASED ON HISTORICAL INFORMATION. THIS PORTION OF BAD DEBT WOULD HAVE BEEN INCLUDED IN CHARITY CARE HAD THE PATIENT COMPLETED THE NECESSARY PAPERWORK. PART III, LINE 4: FOOTNOTE #9 IS LOCATED ON PAGE 27 OF THE ATTACHED AUDITED FINANCIAL STATEMENTS AND DESCRIBES THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. BAD DEBT IS LISTED AS A DEDUCTION FROM REVENUE. THIS TREATEMENT IS CONSISTENT WITH THE HFMA PRINCIPLES AND PRACTICES BOARD STATEMENT NO. 15 AND WITH THE AICPA AUDIT AND ACCOUNTING GUIDE FOR HEALTHCARE ORGANIZATIONS. PART III, LINE 8: KSB HOSPITAL IS A SMALL 80 BED HOSPITAL LOCATED IN RURAL LEE COUNTY IN NORTHERN ILLINOIS. IT WAS ESTIMATED THAT THE POPULATION OF LEE COUNTY WAS 34,735 IN 2014. 17.1% OF THE POPULATION WAS AGE 65 AND OLDER. THE CENSUS BUREAU ESTIMATED THAT BETWEEN 2008-2012, 10% OF LEE COUNTY WAS BELOW THE POVERTY LEVEL. IN 2014, 39.9% OF OUR PAYOR MIX WAS MEDICARE RECIPIENTS. AS A HEALTHCARE PROVIDER WE REALIZE THAT SUBSTANTIAL SHORTFALLS ARISE FROM PAYMENTS THAT ARE LESS THAN WHAT IT COSTS TO PROVIDE CARE OR SERVICE AND DO NOT INCLUDED ANY AMOUNTS THAT RESULT FROM INEFFICIENCIES OR POOR MANAGEMENT. KSB HOSPITAL ACCEPTS ALL MEDICARE PATIENTS KNOWING THAT THERE MAY BE SHORTFALLS, THEREFORE IT HAS TAKEN THE POSITION THAT THEY SHOULD BE COUNTED AS PART OF THE COMMUNITY BENEFIT. ADDITIONALLY, IT IS IMPLIED IN THE INTERNAL REVENUE SERVICE REVENUE RULING 69-545 THAT TREATING MEDICARE PATIENTS IS A COMMUNITY BENEFIT. REVENUE RULING 69-545, WHICH ESTABLISHED THE COMMUNITY BENEFIT STANDARD FOR NON-PROFIT HOSPITALS, STATES THAT IF A HOSPITAL SERVES PATIENTS WITH GOVERNMENTAL HEALTH BENEFITS, INCLUDINGMEDICARE, THEN THIS IS AN INDICATION THAT THE HOSPITAL OPERATES TO PROMOTE THE HEALTH OF THE COMMUNITY.BASED ON KSB HOSPITAL'S FILED 2014 MEDICARE COST REPORT THE MEDICARE ALLOWABLE COSTS FOR 2014 WERE $32,898,575 AND PAYMENTS RECEIVED FROM MEDICARE WERE $24,809,776. WE BELIEVE THAT THE SHORTFALL OF $8,088,799 SHOULD BE CONSIDERED COMMUNITY BENEFIT. PART III, LINE 9B: AFTER THREE STATEMENTS (90) DAYS WITH NO PAYMENT FROM PATIENT, THE ACCOUNT IS ELIGIBLE FOR COLLECTION ACCOUNTS UNDER $500 ARE TO BE PAID OFF IN 6 MONTHS AND OVER $500 PAID OFF WITHIN ONE YEAR. ACCOUNTS THAT HAVE BEEN APPROVED FOR FINANCIAL ASSISTANCE ARE NOT SENT TO COLLECTION. PART VI, LINE 2: KSB HAS A LONGSTANDING HISTORY, IN ADVANCE OF THE COMMUNITY BENEFITS STATUTE, OF WORKING COLLABORATIVELY WITH OTHER ORGANIZATIONS TO ASSESS AND ADDRESS COMMUNITY NEEDS. THERE ARE SEVERAL AREA AGENCIES THAT WE GARNER INFORMATION FROM IN GAUGING THE PULSE OF THE NEEDS OF THE SAUK VALLEY AREA. KSB EXAMINES THE NEEDS OF OUR SERVICE AREA AND RESPONDS THROUGH AVAILABLE PHYSICIANS, OPEN DISCLOSURE FROM OUR PATIENTS, AND INFORMATION FROM COLLABORATIVE AGENCIES. PATIENT OUTREACH SERVICES ARE CONDUCTED WITH COMMUNITY PARTNERS SUCH AS THE LEE COUNTY HEALTH DEPARTMENT, DIXON FAMILY YMCA, YWCA OF THE SAUK VALLEY, SINNISSIPPI CENTERS AND AN ABUNDANCE OF PARTNERS PROVIDING SERVICES TO INDIVIDUALS IN NEED. THESE PROJECTS BRING TOGETHER REPRESENTATIVES OF MANY HEALTH AND HUMAN SERVICE PROVIDER AGENCIES TO UNDERTAKE A COLLABORATIVE APROACH TO UNDERSTAND THE CRUCIAL HEALTH ISSUES IN THE COMMUNITY AND TO PRIORITIZE THOSE PROBLEMS. PART VI, LINE 3: KSB HOSPITAL STRIVES TO EDUCATE OUR PATIENTS OF THEIR ELIGBILITY FOR ASSISTANCE UNDER FEDERAL, STATE, AND LOCAL PROGRAMS. PATIENTS ARE ALSO INFORMED OF OUR CHARITY CARE POLICY. EVERY SELF PAY PATIENT THAT COMES TO THE HSOPITAL IS GIVEN A CHARITY APPLICATION AND OFFERED ASSISTANCE IN HELPING THEM COMPLETE THE APPLICATION. NOTICES ABOUT ASSISTANCE PROGRAMS ARE POSTED IN THE REGISTRATION AREAS AND THE INFORMATION IS ALSO INCLUDED IN THE PATIENT'S STATEMENT AND ON THE KSB WEBSITE. A PATIENT ADVOCATE VISITS EACH INPATIENT WITH A NOTICE OF THEIR INSURANCE BENEFITS AND THEN COUNSELS EACH PATIENT OF ADDITIONAL OPTIONS FOR ASSISTANCE. PART VI, LINE 4: KSB HOSPITAL SERVES LEE COUNTY, A RURAL COUNTY IN NORTHWESTERN ILLINOIS ONE HUNDRED MILES WEST OF CHICAGO AND FORTY-FIVE MILES SOUTHWEST OF ROCKFORD. ACCORDING TO THE U.S. CENSUS BUREAU, THE 2014 POPULATION OF LEE COUNTY WAS ESTIMATED AT 34,735. THE COMMUNITIES OF LEE AND WESTERN OGLE COUNTY COMPRISE THE KSB HOSPITAL PRIMARY SERVICE AREA. THIS AREA SAW A POPULATION DECLINE OF 2.6% BETWEEN 2010 AND 2014, A PERIOD DURING WHICH THE STATE GREW BY 5%. DIXON IS THE COUNTY SEAT AND THE LARGEST COMMUNITY IN LEE COUNTY WITH AN ESTIMATED POPULATION OF 15,333. LEE COUNTY RACE AND ETHNICITY SHOWS 87.2% WHITE, NOT HISPANIC; 5.2% BLACK; 5.7% HISPANIC; WITH THE REMAINING 1.9% AMERICAN INDIAN AND ALASKA NATIVE, ASIAN, OR PERSONS REPORTING TWO OR MORE RACES. LEE COUNTY COVERS 725 SQUARE MILES. PUBLIC TRANSPORTATION IS AVAILABLE THROUGH THE LEE/OGLE TRANSPORTATION SYSTEM AND PRIVATE CAB COMPANIES. ACCORDING TO THE ILLINOIS DEPARTMENT OF EMPLOYMENT SECURITY, THE 2014 ANNUAL AVERAGE UNEMPLOYMENT RATE FOR LEE COUNTY WAS 9.2%, COMPARABLE TO NORTHWEST ILLINOIS OVERALL AND EQUAL TO THE STATE AVERAGE OF 9.2%. WITH A MEDIAN HOUSEHOLD IN INCOME OF $50,060, LEE COUNTY IS LOWER THAN THE STATE AVERAGE OF $56,797. LEE COUNTY PER CAPITA INCOME IS $25,409, BELOW THE STATE AVERAGE OF $29,666. HOWEVER, THE PROPORTION OF LEE COUNTY RESIDENTS, 10.7%, LIVING BELOW THE FEDERAL POVERTY LEVEL IS LOWER THAN THE STATE AVERAGE OF 14.1%. UNINSURED (4.2%) AND MEDICAID (17.0%) PATIENTS COMPRISE A TOTAL OF 21.2% OF OUR PAYER MIX FOR 2014. KATHERINE SHAW BETHEA HOSPITAL IS THE SOLE HOSPITAL IN THE COMMUNITY OF DIXON. THE AREA OF DIXON DOES NOT CONTAIN ANY FEDERALLY DESIGNATED MEDICALLY UNDERSERVED AREAS OR POPULATIONS. PART VI, LINE 5: IN ADDITION TO MEDICAL CARE, SOUND LEADERSHIP AND MANAGEMENT ARE CRITICAL PARTS OF ANY GOOD HOSPITAL. AT KSB HOSPITAL, OUR MISSION AND VISION ARE PUT INTO ACTION EVERY DAY BY AN ADMINISTRATIVE TEAM, A BOARD OF DIRECTORS AND THE MEDICAL STAFF. THESE LEADERS OVERSEE THE HOSPITAL'S OPERATIONS AND MAKE VALUES-BASED DECISIONS THAT ARE CONSISTENT WITH OUR MISSION. THE MAJORITY OF THE BOARD OF DIRECTORS IS COMPRISED OF PERSONS WHO RESIDE IN OUR SERVICE AREA, WHO ARE NEITHER EMPLOYEES NOR INDEPENDENT CONTRACTORS OF THE ORGANIZATION. KSB HAS CLINICS IN 9 LOCATIONS AND THOSE COMMUNITIES ARE WELL REPRESENTED ON THE KSB BOARD. FOR EXAMPLE, TOM SUITS IS FROM THE POLO AREA AND CRAIG CARPENTER LIVES AND WORKS IN OREGON, TWO LOCALES WHERE KSB HAS CLINICS THAT SERVE THOSE COMMUNITIES. OFFERING MORE THAN 60 PHYSICIANS IN A VARIETY OF DISCIPLINES, KSB MEDICAL GROUP ENHANCES HEALTHCARE OPTIONS FOR SAUK VALLEY RESIDENTS. THIS MULTI-SPECIALTY PRACTICE HAS BROUGHT TOGETHER PHYSICIANS WHO ARE NEW TO THE AREA AND THOSE WHO HAVE SPENT AN ENTIRE CAREER IN OUR HOMETOWNS. KSB ALSO EXTENDS AN OPPORTUNITY TO ALL QUALIFIED PHYSICIANS SEEKING PRIVILEGES IN THE SAUK VALLEY SERVICE AREA. KSB UTILIZES ALL SURPLUS FUNDS FOR IMPROVEMENTS IN PATIENT CARE, NEW TECHNOLOGY AND OUR PHYSICAL PROPERTIES. THE LAST YEAR HAS SEEN SIGNIFICANT GROWTH WITHIN AND OUTSIDE THE WALLS OF KSB. IN 2014 WE CONTINUED UPDATING PATIENT ROOMS TO INCLUDE THE LATEST IN TECHNOLOGY AND EQUIPMENT. OUR EDUCATION DEPARTMENT OFFERS A VARIETY OF CLASSES TO EMPLOYEES AND THE PUBLIC. OUR COMMUNITY WELLNESS DEPARTMENT WORKS WITH OTHER COMMUNITY ORGANIZATIONS TO BRING A VARIETY OF HEALTH-RELATED AND WELLNESS PROGRAMS TO THE COMMUNITY. THESE OPPORTUNITIES ARE AN OUTREACH TO THE COMMUNITY THAT ARE FUN AND EDUCATIONAL. A LOOK AROUND AT THE VARIOUS DEPARTMENTS THAT MAKE UP KSB HOSPITAL REVEALS A CONTEMPORARY MEDICAL FACILITY THAT IS PROUD TO OFFER PATIENTS THE FINEST SERVICE POSSIBLE, YET IS NEVER CONTENT TO REST ON ITS PAST ACCOMPLISHMENTS. 1 AMBOY COMMUNITY SCHOOL DISTRICT 272 11 EAST HAWLEY STREET AMBOY IL 61310 366005054 GOVERNMENT 8500 GENERAL OPERATING SUPPORT ASHTON-FRANKLIN CENTER CUSD 611 WESTERN AVENUE ASHTON IL 61006 366008985 GOVERNMENT 6000 GENERAL OPERATING SUPPORT DIXON FAMILY YMCA 110 N GALENA AVENUE DIXON IL 61021 362487927 501(C)(3) 25000 GENERAL OPERATING SUPPORT DIXON PUBLIC SCHOOL DISTRICT 170 1335 FRANKLIN GROVE ROAD DIXON IL 61021 366007311 GOVERNMENT 10000 GENERAL OPERATING SUPPORT HOME OF HOPE CANCER WELLNESS CENTERS 1637 PLOCK ROAD DIXON IL 61021 010743626 501(C)(3) 15000 GENERAL OPERATING SUPPORT NEWMAN CENTRAL HIGH SCHOOL 1101 ST MARYS STREET STERLING IL 61081 362385216 GOVERNMENT 10000 GENERAL OPERATING SUPPORT MEALS ON WHEELS 634 NORTH BEND DRIVE DIXON IL 61021 362905096 501(C)(3) 43219 COST MEALS GENERAL OPERATING SUPPORT OREGON COMMUNITY UNIT SCHOOL DISTRICT 220 206 SOUTH 10TH STREET OREGON IL 61061 362656248 GOVERNMENT 5000 GENERAL OPERATING SUPPORT POLO COMMUNITY UNIT SCHOOL DISTRICT 222 100 UNION AVENUE POLO IL 61064 366008484 GOVERNMENT 5000 GENERAL OPERATING SUPPORT 9 0 STUDENT SCHOLARSHIPS 9 9000 PART I, LINE 2: GRANTS TO OTHER ORGANIZATIONS ARE NOT MONITORED. SCHOLARSHIPS ARE GRANTED BASED ON SET CRITERIA. APPLICATIONS ARE REVIEWED AND RECIPIENTS ARE CHOSEN BY A SCHOLARSHIP COMMITTEE. USE OF SCHOLARSHIPS ARE NOT RESTRICTIVE. X 1 1 X X X X 0 0 0 0 0 1 0 0 0 JOSEPH WELTY MD BOARD MEMBER 244458 0 0 0 3709 0 12322 0 24564 0 285053 0 0 0 DAVID SCHREINER CEO 415967 0 0 0 18925 0 12875 0 48839 0 496606 0 0 0 ALPHEUS APPENHEIMER MD CMO 282458 0 0 0 19425 0 12875 0 23214 0 337972 0 0 0 LINDA CLEMEN CNO 212668 0 0 0 846 0 10778 0 30481 0 254773 0 0 0 DEBRA DIDIER CFO 200293 0 0 0 18355 0 10707 0 27844 0 257199 0 0 0 JULIE MANN CAO 197026 0 0 0 18335 0 10695 0 30103 0 256159 0 0 0 KEVIN MARX CHIEF BUSINESS DEVELOPMENT OFFICER 217914 0 0 0 1283 0 10726 0 16162 0 246085 0 0 0 SULAIMAN MOHAMMAD MD NEUROLOGIST 553984 0 362851 0 17593 0 12875 0 30981 0 978284 0 0 0 MONTHER ELBZOUR MD CARDIOLOGIST 774782 0 82160 0 17562 0 12875 0 30981 0 918360 0 0 0 SOHAIL HANIF MD CARDIOLOGIST 777282 0 0 0 17643 0 12875 0 28481 0 836281 0 0 0 TYLER GUNDERSON MD SURGEON 651686 0 27200 0 20052 0 12875 0 28481 0 740294 0 0 0 IMRE ALMASSY MD RADIOLOGIST 444295 0 200000 0 19819 0 12875 0 24412 0 701401 0 0 0 PART I, LINE 1A THE C-SUITE AND PHYSICIANS RECEIVE REIMBURSEMENT FOR SOME HEALTH AND SOCIAL CLUB DUES. THESE AMOUNTS ARE CONSIDERED TAXABLE COMPENSATION TO THE INDIVIDUAL. PART I, LINE 6 CERTAIN PHYSICIANS THAT ARE CONSIDERED "PERSONS OF INTEREST" RECEIVE BONUSES BASED ON NET CASH COLLECTIONS OF THEIR INDIVIDUAL PRACTICE. KAILE VALDEZ FAMILY MEMBER OF DAVID SCHREINER, CURRENT OFFICER/TRUSTEE 22563 EMPLOYEE COMPENSATION 0 ALPHEUS B APPENHEIMER FAMILY MEMBER OF TIM APPENHEIMER, OFFICER 110449 EMPLOYMENT COMPENSATION 0 STACEY APPENHEIMER FAMILY MEMBER OF TIM APPENHEIMER, OFFICER 69275 EMPLOYMENT COMPENSATION 0 DAN MANN FAMILY MEMBER OF JULIE MANN, OFFICER 21199 EMPLOYMENT COMPENSATION 0 LESLIE MANN FAMILY MEMBER OF JULIE MANN, OFFICER 53382 EMPLOYMENT COMPENSATION 0 SCHEDULE L, PART IV KSB IS ONE OF THE LARGEST EMPLOYERS IN LEE COUNTY, ILLINOIS AND IT IS VERY COMMON IN LESSER POPULATED RURAL AREAS FOR FAMILY MEMBERS TO WORK AT SUCH A SIGNIFICANT EMPLOYER. FORM 990, PART VI, SECTION A, LINE 1 THE EXECUTIVE CONSISTS OF THE OFFICERS OF THE BOARD OF DIRECTORS AND ONE OTHER MEMBER OF THE BOARD OF DIRECTORS. THE EXECUTIVE COMITTEE HAS THE POWER TO TRANSACT ALL REGULAR BUSINESS OF THE HOSPITAL DURING THE INTERIM BETWEEN BOARD MEETINGS AS LONG AS SUCH ACTION DOES NOT CONFLICT WITH THE POLICIES AND EXPRESSED WISHES OF THE BOARD. FORM 990, PART VI, SECTION A, LINE 7A BOARD MEMBERS ARE ELECTED BY A MAJORITY VOTE OF THE CITY COUNCIL OF THE CITY OF DIXON, ILLINOIS. IF TWO-THIRDS OR MORE OF THE BOARD POSITIONS ARE VACATED IN ANY ONE YEAR, THE MAYOR OF THE CITY OF DIXON, ILLINOIS, WOULD HAVE THE POWER TO APPOINT ALL BOARD MEMBERS TO FILL SUCH VACANCIES. FORM 990, PART VI, SECTION B, LINE 11 FULL COMPLETE COPIES OF THE FORM 990 ARE PROVIDED TO THE ENTIRE GOVERNING BODY AND MANAGEMENT PRIOR TO FILING, WITH A REVIEW AT THE BOARD MEETING TO ADDRESS ANY QUESTIONS THAT MAY ARISE. FORM 990, PART VI, SECTION B, LINE 12C ON AN ANNUAL BASIS, A CONFLICT OF INTEREST QUESTIONNAIRE IS DISTRIBUTED TO ALL MEMBERS OF THE GOVERNING BODY AND MANAGEMENT TO IDENTIFY ANY CONFLICTS OF INTEREST IN ADDTION, ON AN ONGOING BASIS, PRIOR TO EACH BOARD ACTION, EACH VOTING OFFICER IS RESPONSBILE TO SELF EVALUATE TO DETERMINE WHETHER A CONFLICT OF INTEREST IS PRESENT. AN INDIVIDUAL WITH A POTENTIAL CONFLICT DISCLOSES THE MATTER TO THE BOARD OR COMMITTEE. AFTER DISCLOSURE OF THE RELEVANT FACTS, THAT INDIVIDUAL LEAVES THE ROOM WHILE THE REMAINING BOARD OR COMMITTEE MEMBERS VOTE ON WHETHER A CONFLICT OF INTEREST EXISTS. IN THE INSTANCE THAT CONFLICT EXISTS, THE NECESSARY PARTIES ARE EXCUSED FROM THE ROOM WHILE THE REMAINING BOARD OR COMMITTEE MEMBERS DISCUSS THE TRANSACTION AND VOTE ON THE MATTER. IF AN INDIVIDUAL FAILS TO DISCLOSE A CONFLICT, THE BOARD WILL TAKE APPROPRIATE DISCIPLINARY AND CORRECTIVE ACTION. FORM 990, PART VI, SECTION B, LINE 15A THE ORGANZATION ENGAGES AN OUTSIDE CONSULTANT TO PROVIDE COMPARABILITY COMPENSATION DATA FOR THE CEO POSTION. THE OUTSIDE CONSULTANT PROVIDES THE BOARD WITH A SUGGESTED RANGE FOR COMPENSATION. THE BOARD AND COMPENSATION COMMITTEE THEN REVIEWS THE INFORMATION RECEIVED AND DETERMINES THE COMPENSATION OF THE CEO WITH LEGAL COUNSEL. THE BOARD APPROVES IN ADVANCE AND DOCUMENTS THE COMPENSATION DETERMINATIONS IN THE BOARD MINUTES ON A TIMELY BASIS. A FIVE YEAR CONTRACT WAS NEGOTATED IN 2010. THIS CONTRACT IS IN EFFECT FOR 2014. THE VICE PRESIDENTS' (CFO, CNO, CPO(CHIEF PRACTICE OFFICER), CMO AND CAO) COMPENSATION ARE DETERMINED BY PROVIDING THE CEO WITH COMPARABILITY DATA. THE COMPARABILITY DATA IS GATHERED BY THE HUMAN RESOURCES DEPARTMENT. THE CEO DETERMINES THE APPROPRIATE COMPENSATION FOR THE VICE PRESIDENTS AND PRESENTS A REPORT TO THE COMPENSATION COMMITTEE. PHYSCICIAN COMPENSATION IS NEGOTIATED AT THE TIME OF CONTRACT RENEWAL. THE ORGANZATION ENGAGES AN OUTSIDE CONSULTANT TO PROVIDE COMPARABILITY DATA FOR THE PHYSICIANS. FORM 990, PART VI, SECTION C, LINE 19 FINANCIAL STATEMENTS, GOVERNING DOCUMENTS AND CONFLICTS OF INTEREST POLICIES ARE NOT REQUIRED DISCLOSURES PURSUANT TO IRC SECTION 6104. PORTIONS OF THE FINANCIAL STATEMENTS ARE PUBLISHED IN THE ANNUAL REPORT THAT IS MAILED TO THE LOCAL COMMUNITY. THE GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE NOT AVAILABLE TO THE PUBLIC AT THIS TIME. KSB HOSPITAL AUXILIARY 403 E FIRST STREET DIXON IL 61021 366192116 FUNDRAISING IL 501(C)(3) LINE 11D, III-O KATHERINE SHAW BETHEA HOSPITAL 1 THE OREGON PARTNERSHIP 2400 N ROCKTON AVENUE ROCKFORD IL 61103 HEALTHCARE OFFICES IL KATHERINE SHAW BETHEA HOSPITAL RELATED -80964 551507 0 1 0.72600 KSB VENTURES INC 403 EAST 1ST STREET DIXON IL 61021 465278274 HOLD PARTNERSHIP INVESTMENT IL KATHERINE SHAW BETHEA HOSPITAL C 266758 551537 1.00000 0 0 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0