2015-11-13T08:59:21-06:00 2014-12-31 351178661 BLUE & CO LLC 8800 LYRA DRIVE SUITE 450 COLUMBUS OH 43240 990 2014-01-01 344427944 THE SHELBY COUNTY MEMORIAL HOSPITAL ASSOCIATION SHEL 9374982311 915 WEST MICHIGAN STREET SIDNEY OH 453652491 JULIE COVAULT VP - FINANCE 9374982311 2015-11-12 1 STEPHEN A SHERIDAN P00028551 6148852583 2015-11-12 2014 2016-02-25 16:41:14Z WILSON MEMORIAL HOSPITAL JULIE COVAULT 915 WEST MICHIGAN STREET SIDNEY OH 453652491 97844326 0 X WWW.WILSONHOSPITAL.COM X 1920 OH TO MAINTAIN A PATIENT-CENTERED ENVIRONMENT THAT ENCOURAGES AND SUPPORTS INNOVATION AND TEAMWORK IN ACHIEVING EXCELLENCE. TO MAXIMIZE CUSTOMER SATISFACTION BY MEETING THE HIGHEST STANDARDS OF VALUE, SERVICE, AND PERFORMANCE. TO PROVIDE COMMUNITY LEADERSHIP BY ASSURING ACCESS TO THE HIGHEST QUALITY, COMPREHENSIVE HEALTH CARE SERVICES. 15 14 846 189 0 0 74874 1031734 85664451 93706234 2143211 1023275 3410256 1888083 91292792 97649326 0 0 0 0 44217830 47029900 0 0 0 40406036 41831434 84623866 88861334 6668926 8787992 103903853 110640475 12907178 10478284 90996675 100162191 X TO MAINTAIN A PATIENT-CENTERED ENVIRONMENT THAT ENCOURAGES AND SUPPORTS INNOVATION AND TEAMWORK IN ACHIEVING EXCELLENCE. TO MAXIMIZE CUSTOMER SATISFACTION BY MEETING THE HIGHEST STANDARDS OF VALUE, SERVICE, AND PERFORMANCE. TO PROVIDE COMMUNITY LEADERSHIP BY ASSURING ACCESS TO THE HIGHEST QUALITY, COMPREHENSIVE HEALTH CARE SERVICES. 0 0 26675038 26717846 INPATIENT HEALTHCARE SERVICES - THERE WERE 3,478 ADMISSIONS TO THE HOSPITAL IN 2014, REPRESENTING 12,569 PATIENT DAYS OF CARE. THERE WERE 513 INPATIENT SURGERIES PERFORMED DURING 2014. 17217827 20067360 OUTPATIENT HEALTHCARE SERVICES - THERE WERE 75,519 OUTPATIENT REGISTRATIONS RECORDED IN 2014. 11830428 13239783 SAME DAY SURGERY - THERE WERE 3,126 OUTPATIENT SURGERIES PERFORMED AT THE HOSPITAL IN 2014. 22270300 27581159 THERE WERE 26,567 EMERGENCY VISITS AT THE HOSPITAL IN 2014THERE WERE 16,989 OCCUPATIONAL HEALTH VISITS RECORDED FOR 2014THERE WERE 100,177 OFFICE VISITS IN THE WILSON CARE, LLC OFFICES IN 2014THERE WERE 18,740 HOME HEALTH AND 4,719 HOSPICE VISITS IN 2014 22270300 27581159 77993593 1 1 0 0 0 0 0 0 0 1 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 1 1 1 0 0 0 0 1 1 0 0 0 1 134 0 1 846 0 0 0 0 0 0 0 0 0 0 0 X 15 14 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 OH X JULIE COVAULT 9374982311 915 WEST MICHIGAN STREET SIDNEY OH 45365 DAN BENSMAN TRUSTEE 1.00 X 0 0 0 STAN CROSLEY VICE-CHAIR 1.00 X X 0 0 0 GERALD DOERGER TRUSTEE 1.00 X 0 0 0 FRED HAUSSMAN MD TRUSTEE 1.00 1.00 X 0 0 0 RUDY KEISTER SECRETARY 1.00 X X 0 0 0 DAVE MONNIER TREASURER 1.00 X X 0 0 0 KENNETH MONNIER CHAIRMAN 1.00 1.00 X X 0 0 0 JEFF RAIBLE TRUSTEE 1.00 X 0 0 0 TOM SHEEHAN TRUSTEE 1.00 X 0 0 0 JOHN SPOLTMAN TRUSTEE 1.00 X 0 0 0 TONYA THIEMAN TRUSTEE 1.00 X 0 0 0 BOB WHEELER TRUSTEE 1.00 X 0 0 0 ANDY COUNTS TRUSTEE 1.00 X 0 0 0 MARK DOOLEY PRESIDENT AND CEO 40.00 X X 178854 0 17070 PATTI ROSS TRUSTEE 1.00 X 0 0 0 THOMAS BOECKER CEO 40.00 X 507044 0 109394 JULIE COVAULT VP-FINANCE 40.00 X 170920 0 46652 CRAIG LANNOYE VP-OPERATIONS 40.00 X 196065 0 68486 LINDA MAURER VP-NURSING & PATIENT CARE 40.00 X 160100 0 46828 VALERIE SCHULTTE PHYSICIAN 40.00 X 461517 0 53193 CECILIA BANGA PHYSICIAN 40.00 X 282218 0 15429 FREDERICK SIMPSON PHYSICIAN 40.00 X 294448 0 66919 KAREN SMITH PHYSICIAN 40.00 X 294582 0 40449 RUDY BOHINE PHYSICIAN 40.00 X 289363 0 13893 2835111 0 478313 10 0 1 0 KETTERING ANESTHESIA ASSOCIATES INC 300 PENTAGON BEAVERCREEK OH 45431 ANESTHESIOLOGISTS 823090 WILSON SLEEP LLC 915 WEST MICHIGAN STREET SIDNEY OH 45365 SLEEP LAB STUDIES 631070 LABORATORY CORPORATON OF AMERICAN HOLDIN P O BOX 12140 BURLINGTON NC 27216 LABORATORY SERVICES 471869 PREMIER HEALTH CARE SERVICES INC P O BOX 634485 CINCINNATI OH 452634850 ER PHYSICIANS 463464 PREMIER PHYSICIAN SERVICES P O BOX 637682 CINCINNATI OH 452637682 OCC MED PHYSICIANS 338581 11 904965 126769 1031734 NET PATIENT SERVICE REVENUE 900099 93706234 93706234 93706234 1153637 1153637 489563 0 489563 489563 489563 64638 0 195000 64638 -195000 -130362 -130362 REBATES 900099 347804 347804 DIETARY 722210 337315 337315 INVESTMENT IN JOINT VENTURES 900099 337001 337001 376400 62991 313409 1398520 97649326 94454030 0 2163562 X 34647844 30410413 4237431 1611444 1414364 197080 8358173 7335968 1022205 2412439 2117398 295041 150000 131655 18345 106939 93860 13079 37803 33180 4623 14044495 12326854 1717641 126227 110789 15438 220984 193958 27026 2502084 2196079 306005 125853 110461 15392 275259 241595 33664 145620 127811 17809 5574866 4893060 681806 893441 784173 109268 MEDICAL AND OTHER SUPPL 10585257 9290680 1294577 BAD DEBTS 5940357 5213851 726506 MISCELLANEOUS 1102249 967444 134805 88861334 77993593 10867741 0 3600 11394665 12594418 9719459 10372679 1034554 1109845 1200773 1545286 97798526 61306896 37528835 36491630 32776661 36651105 441107 494454 9804199 11381058 103903853 110640475 3171150 2515974 4852483 3727476 100000 4883545 4134834 12907178 10478284 X 83126084 91741849 7870591 8420342 90996675 100162191 103903853 110640475 X 8787992 -21665 399189 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED PART II-B, LINE 1: PERCENTAGE OF OHA DUES USED IN LOBBYING IS 3.4% 179168 10809 189977 173542 5626 179168 162670 10872 173542 163551 2915 3796 162670 157308 6243 163551 0.55000 0.45000 0 0 589676 589676 52507062 29904295 22602767 43351323 31402601 11948722 1350465 1350465 36491630 ACCRUED INTEREST 15302 DEFERRED FINANCING COSTS 21850 INTEREST IN FOUNDATION'S ASSET 8420342 OTHER A/R 457544 INSURANCE DEPOSIT 1000 ESTIMATED THIRD-PARTY SETTLEMENTS 1603883 MEANINGFUL USE 861027 OTHER ASSETS 110 11381058 ACCRUED EMPLOYEE COMPENSATION AND RELATED TAXES 3663104 DEFERRED COMPENSATION PAYABLE 471730 4134834 X PART V, LINE 4: THE ENDOWMENT FUNDS WERE ESTABLISHED FOR A VARIETY OF PURPOSES. THE ENDOWMENT FUNDS CONSIST OF FOUR SEPARATE FUNDS, INCLUDING THE MARY KEISER HOSPICE FUND, THE RUTH HEALTH AND EQUIPMENT FUND, THE ROSS HOME HEALTH CARE AND HOSPICE FUND, AND THE CRIMM FUND FOR SURGICAL EQUIPMENT. PART X, LINE 2: SCHEDULE D, PART X LINE 2: ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA REQUIRE MANAGEMENT TO EVALUATE TAX POSITIONS TAKEN AND RECOGNIZE A TAX LIABILITY IF AN UNCERTAIN POSITION HAS BEEN TAKEN 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 THESE ENTITIES AND HAS CONCLUDED THAT AS OF DECEMBER 31, 2014 AND 2013, THERE ARE NO UNCERTAIN POSITIONS TAKEN OR EXPECTED TO BE TAKEN THAT WOULD REQUIRE RECOGNITION OF A LIABILITY OR DISCLOSURE IN THE ACCOMPANYING FINANCIAL STATEMENTS. THE ENTITIES ARE SUBJECT TO ROUTINE AUDITS BY TAXING JURISDICTIONS; HOWEVER, THERE ARE CURRENTLY NO AUDITS FOR ANY TAX PERIODS IN PROGRESS. 1 1 1 X 1 X 1 1 0 1 1 1066377 1066377 0.01500 13073257 10505831 2567426 0.03610 14139634 10505831 3633803 0.05110 66623 66623 0.00000 66623 66623 14206257 10505831 3700426 0.05110 1 5940357 150592 15010757 18314622 -3303865 X 1 1 1 WILSON SLEEP LLC SLEEP STUDIES 0.60000 0.00000 0.40000 2 HONDA HEALTH PARTNERS PROVIDING OCCUPATIONAL HEALTH SERVICES TO HONDA 0.33330 0.00000 0.00000 1 1 SHELBY COUNTY MEMORIAL HOSPITAL ASSOC 915 W MICHIGAN STREET SIDNEY OH 45365 X X X THE SHELBY COUNTY MEMORIAL HOSPITAL 1 0 0 1 X X X X X X X X X 13 1 0 0 1 X HTTP://WWW.WILSONHEALTH.ORG/COMMUNITY-HEALTH-NEEDS-ASSESSMENT X HTTP://SHELBYCOUNTYHEALTHDEPT.ORG 1 13 1 HTTP://WWW.WILSONHEALTH.ORG/COMMUNITY-HEALTH-NEEDS-ASSESSMENT 0 0 1 X 100.000000000000 200.000000000000 X X 1 1 X X 1 X X X X X 1 0 X X 1 0 1 THE SHELBY COUNTY MEMORIAL HOSPITAL PART V, SECTION B, LINE 5: THE 2013 CHNA RESEARCH EFFORTS INCLUDED: INTERVIEWS WITH 30 COMMUNITY LEADERS; A DEMOGRAPHIC ANALYSIS; A SURVEY OF NEARLY 2,000 MIDDLE AND HIGH SCHOOL STUDENTS; AND A SURVEY OF 400 ADULT RESIDENTS. BEYOND THAT, WILSON MEMORIAL COLLABORATED WITH THE GREATER DAYTON AREA HOSPITAL ASSOCIATION AND WRIGHT STATE UNIVERSITY TO STUDY SECONDARY DATA SUCH AS VITAL STATISTICS, CANCER TRENDS, AND HOSPITAL AND EMERGENCY DEPARTMENT DISCHARGE DATA. THE STEERING COMMITTEE MET 10 TIMES TO ANALYZE THE RESULTS AND IDENTIFY HEALTH PRIORITIES. COMMUNITY FORUMS WERE HELD TO PRESENT KEY FINDINGS, RECOGNIZING THAT AN INFORMED COMMUNITY WILL ENHANCE THE PARTNERSHIP THAT COMMUNITY IMPROVEMENT REQUIRES. THE SHELBY COUNTY MEMORIAL HOSPITAL PART V, SECTION B, LINE 22D: ALL PATIENTS ARE CHARGED THE SAME GROSS CHARGE REGARDLESS OF PAYOR SOURCE. FAP ELIGIBLE INDIVIDUALS WILL QUALIFY FOR A MINIMUM OF A 30% DISCOUNT. THE SHELBY COUNTY MEMORIAL HOSPITAL PART V, SECTION B, LINE 24: ALL PATIENTS ARE CHARGED THE SAME GROSS CHARGE REGARDLESS OF PAYOR SOURCE. FAP ELIGIBLE INDIVIDUALS WILL QUALIFY FOR A MINIMUM OF A 30% DISCOUNT. PART V, SECTION B, LINE 16 FINANCIAL ASSISTANCE POLICY WEBSITE AVAILABILITY THE SHELBY COUNTY MEMORIAL HOSPITAL PART V, SECTION B, LINE 16A WEBSITE: HTTP://WWW.WILSONHEALTH.ORG THE SHELBY COUNTY MEMORIAL HOSPITAL PART V, SECTION B, LINE 16B WEBSITE: HTTP://WWW.WILSONHEALTH.ORG 2 WILSON HOME HEALTH AND HOSPICE 1081 FAIRINGTON STREET SIDNEY OH 45365 HOME HEALTH WILSON SLEEP LLC 915 WEST MICHIGAN STREET SIDNEY OH 45365 SLEEP SERVICES PART II, COMMUNITY BUILDING ACTIVITIES: N/A PART III, LINE 4: NET PATIENT SERVICE REVENUE IS RECOGNIZED AS SERVICES ARE PERFORMED AND IS REPORTED BASED ON CHARGES, NET OF CERTAIN DEDUCTIONS FROM THOSE CHARGES. DEDUCTIONS ARE BASED ON THE DIFFERENCE BETWEEN CHARGES AT ESTABLISHED RATES AND AMOUNTS ESTIMATED BY MANAGEMENT TO BE REIMBURSABLE BY THIRD-PARTY PAYORS. REIMBURSABLE AMOUNTS ARE GENERALLY LESS THAN THE ESTABLISHED CHARGES. FINAL DETERMINATION OF AMOUNTS EARNED FOR PATIENTS IS SUBJECT TO REVIEW BY PROGRAM REPRESENTATIVES. SUBSEQUENT ADJUSTMENTS, IF ANY, ARISING FROM SUCH REVIEW ARE RECORDED IN THE YEAR THEY BECOME KNOWN.THE HOSPITAL HAS A DETAILED FINANCIAL ASSISTANCE POLICY WHICH STATES THAT TO PARTICIPATE IN CHARITY CARE CANDIDATES MUST COOPERATE FULLY. IN ADDITION THE HOSPITAL EDUCATES PATIENTS WILL LIMITED ABILITY TO PAY REGARDING FINANCIAL ASSISTANCE. FOR THIS REASON THE ORGANIZATION BELIEVES THAT 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 ELDERLY ARE OFTEN AN UNDERSERVED POPULATION THAT EXPERIENCE ISSUES REGARDING ACCESS TO HEALTHCARE SERVICES. MEDICARE IS OUR LARGEST PAYER, AND HOSPITALS MUST ACCEPT MEDICARE PATIENTS REGARDLESS OF WHETHER THEY HAVE A SURPLUS OR DEFICIT FROM PROVIDING THESE SERVICES. PROVIDING MEDICARE SERVICES PROMOTES ACCESS TO HEALTHCARE SERVICES WHICH IS A COMMUNITY BENEFIT. IF TAX EXEMPT HOSPITALS DID NOT PROVIDE MEDICARE SERVICES, THE FEDERAL GOVERNMENT WOULD BEAR THE BURDEN OF DIRECTLY PROVIDING SERVICES TO THE MEDICARE ELIGIBLE. PART III, LINE 9B: IN ORDER FOR THE HOSPITAL TO CONTINUE OPERATING EFFICIENTLY, THE FOLLOWING COLLECTION POLICY HAS BEEN ADOPTED.A. EACH PATIENT/GUARANTOR IS INDIVIDUALLY RESPONSIBLE FOR PAYMENT OF ALL CHARGES UNLESS HIS/HER THIRD-PARTY PAYER HAS A CONTRACT WITH THE HOSPITAL.B. THE HOSPITAL WILL ACCEPT ASSIGNMENT OF HEALTH INSURANCE BENEFITS FOR MEDICARE, MEDICAID, TRICARE, AND OTHERS PER INDIVIDUAL CONTRACT.1. DEDUCTIBLE, CO-INSURANCE, OR NON-COVERED SERVICES ARE PAYABLE AT THE TIME OF SERVICE UNLESS FINANCIAL ARRANGEMENTS HAVE BEEN MADE WITH THE FINANCIAL ADVISOR.2. ANY BALANCE AFTER THE APPLICATION OF HEALTH INSURANCE PAYMENTS TO THE PATIENT'S ACCOUNT IS TO BE PAID WITHIN THIRTY (30) DAYS FOLLOWING NOTIFICATION. IF PAID WITHIN 30 DAYS OF RECEIPT OF FIRST STATEMENT, PATIENT IS ELIGIBLE FOR A 10% DISCOUNT ON THE BALANCE OF THE BILL.3. THE HOSPITAL WILL ACCEPT MASTER CARD, VISA, AND DISCOVER CHARGE CARDS FOR PAYMENTS ON PATIENT ACCOUNTS.4. PAYMENTS OR ARRANGEMENT FOR PAYMENT PLANS ARE TO COMMENCE WITHIN THIRTY (30) DAYS OF BILL DATE. 5. PATIENTS ARE ASKED TO "PAY IN FULL" HOWEVER, IF THE PATIENT/GUARANTOR INDICATES AN INABILITY TO MAKE PAYMENT IN FULL, THE PATIENT/GUARANTOR WILL BE GIVEN THE OPTION TO ESTABLISH A CONTRACT ACCOUNT WITH WILSON MEMORIAL HOSPITAL.A MONTHLY CONTRACT ACCOUNT CAN BE ESTABLISHED. THE MONTHLY AGREEMENT MUST BE SET UP SO THAT THE ENTIRE AMOUNT WILL BE PAID OFF IN TWELVE MONTHS, UNLESS OTHERWISE APPROVED BY DIRECTOR OF PATIENT FINANCIAL SERVICES. NO MONTHLY PAYMENT WILL BE LESS THAN $25.00IF THE PATIENT OR ANY FAMILY MEMBER OF THE RESPONSIBLE PARTY OR GUARANTOR'S FAMILY IS CURRENTLY PAYING ON A BILL AND HAS NEED OF THE HOSPITAL'S SERVICES AGAIN, THE PAYMENT MUST THEN BE ADJUSTED UPWARDS TO REFLECT THE NEXT BALANCE DUE.WILSON MEMORIAL HOSPITAL EMPLOYEES, ALONG WITH THEIR SPOUSE AND CHILDREN UNDER THE AGE OF EIGHTEEN, WHO INDICATE DIFFICULTY IN MEETING PAYMENT OBLIGATIONS ON THEIR ACCOUNT ARE GIVEN THE OPTION TO MAKE MONTHLY PAYMENTS, OR HAVE PAYMENTS DEDUCTED FROM THEIR PAY CHECK. (PAYROLL DEDUCTION PROGRAM)PAYMENT ON THE ACCOUNTS NOT RECEIVED ACCORDING TO THE ABOVE PROVISION WILL BE SUBJECT TO BECOMING A "DELINQUENT ACCOUNT". ACTIONS TAKEN BY THE HOSPITAL TOWARD SUCH ACCOUNTS WILL BE AT THE HOSPITAL'S DISCRETION.THE HOSPITAL RETAINS THE RIGHT TO REFER THE PATIENT'S DELINQUENT ACCOUNTS TO A PROFESSIONAL COLLECTION AGENCY.THE FIRST STATEMENT A PATIENT RECEIVES WILL BE SENT OUT BY WILSON HOSPITAL. IF WITHIN 30 DAYS THERE HAS BEEN NO PAYMENT ON THE ACCOUNT, IT WILL BE SENT TO OUR EARLY OUT PROGRAM. THEY WILL ACT AS A WILSON MEMORIAL FINANCIAL ADVISOR AND RECEIVE A PERCENTAGE OF THE ACCOUNT IF ANY PAYMENT IS MADE TO THEM. IF THE EARLY OUT AGENCY CANNOT COLLECT ON THE ACCOUNTS, THEY ARE SENT BACK TO THE HOSPITAL TO BE SENT TO ONE OF 3 COLLECTION AGENCIES.DIRECTOR OF PATIENT FINANCIAL SERVICES MUST APPROVE ALL ACCOUNTS SENT TO THE COLLECTION AGENCY AND MUST APPROVE ANY LEGAL ACTION THAT IS SUGGESTED BY THE COLLECTION AGENCY.WILSON MEMORIAL HOSPITAL IS REQUIRED BY LAW TO GIVE "FREE CARE"TO THOSE PERSONS WHO ARE ELIGIBLE BASED ON STATE STATUTES.WILSON MEMORIAL HOSPITAL HAS A CHARITY CARE POLICY FOR THOSE ELIGIBLE WHO CANNOT AFFORD TO PAY FOR CARE. THE CURRENT FEDERAL POVERTY INCOME GUIDELINES WILL BE USED TO DETERMINE ELIGIBILITY OF THE PATIENT.ANY HOSPITAL SERVICES RESULTING FROM AN ACCIDENT OR OTHER CAUSES INVOLVING A DISPUTE AS TO LIABILITY BETWEEN THE PATIENT AND OTHERS, DOES NOT INVOLVE THE HOSPITAL. THE HOSPITAL WILL EXPECT PAYMENT IN THE SAME MANNER AS ALL OTHER SERVICES. THE HOSPITAL WILL ACCEPT A LETTER OF PROTECTION FOR A DURATION OF 90 DAYS. AFTER 90 DAYS THE HOSPITAL WILL ACTIVELY PURSUE THE PATIENT OR GUARANTOR FOR PAYMENT OF RENDERED SERVICES.EXCEPTIONS TO THE ABOVE ITEMS CAN BE MADE WITH THE APPROVAL OF THE DIRECTOR OF PATIENT FINANCIAL SERVICES. ALL UNUSUAL ARRANGEMENTS AND CIRCUMSTANCES ARE REVIEWED AND APPROVED BY THE VICE PRESIDENT OF FINANCE. SCH H PT V, LINE 22 IN FULFILLING WILSON MEMORIAL HOSPITAL'S MISSION, WE RECOGNIZE THAT WE WILL NOT RECEIVE PAYMENT FROM CERTAIN INDIVIDUALS FOR CARE THAT HAS BEEN RENDERED, AND A CERTAIN DEGREE OF JUDGMENT WILL BE REQUIRED IN DETERMINING CHARITY CARE LEVELS OF THE PATIENTS.POLICYWILSON MEMORIAL HOSPITAL IS A NOT-FOR-PROFIT ENTITY ESTABLISHED TO MEET THE HEALTH CARE NEEDS OF ALL CITIZENS OF SIDNEY AND SURROUNDING COMMUNITIES. WILSON MEMORIAL HOSPITAL WILL PROVIDE CHARITABLE CARE FOR THOSE INDIVIDUALS WHO CAN DEMONSTRATE THE INABILITY TO PAY BASED ON THEIR FINANCIAL STATUS AS IT RELATES TO HOSPITAL AND FEDERAL POVERTY LEVEL GUIDELINES.RESPONSBILITYTHE HOSPITAL HAS A LEGAL AND MORAL OBLIGATION TO PROVIDE EMERGENCY, TRAUMA AND OBSTETRICAL CARE BEFORE DETERMINING THE SOURCE OF PAYMENT.ELIGIBILITY REQUIREMENTSI. ALL WILSON MEMORIAL HOSPITAL PATIENTS WHO ARE UNABLE TO PAY FOR HOSPITAL SERVICES WILL BE ELIGIBLE TO APPLY FOR CHARITY ASSISTANCE.II. CHARITY ASSISTANCE MAY BE APPROVED ON TOTAL OR PARTIAL PATIENT RESPONSIBILITY. DOLLAR AMOUNTS ARE BASED ON FINANCIAL INFORMATION SUPPLIED BY THE PATIENT.III. PATIENTS WILL BE ELIGIBLE FOR TOTAL CHARITY ASSISTANCE IF:A. THE PATIENT IS INELIGIBLE FOR PUBLIC ASSISTANCE (MEDICAID, GENERAL ASSISTANCE, ETC.).B. THE PATIENT COMPLETES A FINANCIAL STATEMENT INDICATING CURRENT EARNINGS, EXPENSES AND PERSONAL/FAMILY INFORMATION. WE WILL ACCEPT THE PATIENT'S DECLARATION OF INCOME.C. THE PATIENTS AND/OR FAMILY INCOME DOES NOT EXCEED THE POVERTY GUIDELINES AS ESTABLISHED BY THE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES.IV. PATIENTS WILL BE ELIGIBLE FOR PARTIAL CHARITY ASSISTANCE IF:A. THE PATIENT IS INELIGIBLE FOR PUBLIC ASSISTANCE (MEDICAID, GENERAL ASSISTANCE, ETC.) EITHER OR PARTIAL COVERAGE.B. THE PATIENT COMPLETES A FINANCIAL STATEMENT INDICATING CURRENT EARNINGS, EXPENSES AND PERSONAL/FAMILY INFORMATION. WE WILL ACCEPT THE PATIENT'S DECLARATION OF INCOME.C. THE PATIENTS AND/OR FAMILY INCOME DOES NOT EXCEED TWO TIMES THE POVERTY GUIDELINES AS ESTABLISHED BY THE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES.D. THE PATIENT AND/OR FAMILY INCOME EXCEEDS TWO TIMES THE INCOME POVERTY/GUIDELINES, DETERMINATION OF ELIGIBILITY AND AMOUNT OF CHARITY CARE WILL BE BASED ON FINANCIAL STATEMENT FROM PATIENT ON AN ACCOUNT BY ACCOUNT BASIS.V. PATIENTS MAY NOT BE ELIGIBLE FOR CHARITY CARE ASSISTANCE IF THE PROCEDURE PROVIDED IS ELECTIVE. EACH INSTANCE WILL BE REVIEWED ON A CASE BY CASE BASIS WITH MEDICAL STAFF AND MANAGEMENT INPUT. PART VI, LINE 2: THE ANNUAL STRATEGIC PLANNING PROCESS UTILIZES MARKET DATA WHICH SHOWS SERVICES THAT SHELBY COUNTY RESIDENTS LEAVE TO OBTAIN ELSEWHERE. INPUT IS PROVIDED BY COMMUNITY MEMBERS WHO SIT ON HOSPITAL BOARD. PART VI, LINE 3: INCOME ELIGIBLITY GUIDELINES ARE CONSPICUOUSLY POSTED AT ALL REGISTRATION POINTS. IN ADDITION, THE GUIDELINES ARE PRINTED ON PATIENT STATEMENTS AND BILLS. THE HOSPITAL EMPLOYS FINANCIAL COUNSELORS WHO MEET PERSONALLY AND BY PHONE WITH PATIENTS TO ASSIST THEM IN COMPLETING FORMS TO DETERMINE THE EXTENT OF THEIR ELIGIBLITY FOR ANY FINANCIAL ASSISTANCE. PART VI, LINE 4: THE PRIMARY SERVICE AREA IS SHELBY AND SURROUNDING COUNTIES. WITH THE EXCEPTION OF MIAMI COUNTY TO THE SOUTH ALL OF THE SERVICE AREA IS CONSIDERED RURAL. PART VI, LINE 5: THE SHELBY COUNTY MEMORIAL HOSPITAL ASSOCIATION'S BOARD OF TRUSTEES IS COMPRISED OF VOLUNTEERS FROM OUR COMMUNITY. THE MAJORITY OF OUR BOARD MEMBERS LIVE AND WORK WITHIN THE COMMUNITY AND ARE ACTIVELY INVOLVED WITH OTHER NON-PROFIT AGENCIES. THE MAJORITY OF OUR SENIOR MANAGERS AND STAFF ALSO LIVE IN OUR PRIMARY SERVICE AREA AND MANY SIT ON OTHER COMMUNITY BASED GOVERNANCE BOARDS. THE "SPIRIT" OF COMMUNITY BASED HEALTHCARE RESIDES IN OUR BOARD OF TRUSTEES AND HOSPITAL STAFF AND IS FURTHER EVIDENCED BY OUR OPEN MEDICAL STAFF. X 1 1 X X X X 0 1 0 0 0 0 0 0 0 MARK DOOLEY PRESIDENT AND CEO 149714 0 0 0 29140 0 0 0 17070 0 195924 0 0 0 THOMAS BOECKER CEO 409450 0 76970 0 20624 0 86481 0 22913 0 616438 0 0 0 JULIE COVAULT VP-FINANCE 161256 0 0 0 9664 0 14584 0 32068 0 217572 0 0 0 CRAIG LANNOYE VP-OPERATIONS 183468 0 0 0 12597 0 34578 0 33908 0 264551 0 0 0 LINDA MAURER VP-NURSING & PATIENT CARE 150248 0 0 0 9852 0 13605 0 33223 0 206928 0 0 0 VALERIE SCHULTTE PHYSICIAN 403357 0 0 0 58160 0 11025 0 42168 0 514710 0 0 0 CECILIA BANGA PHYSICIAN 261734 0 0 0 20484 0 11025 0 4404 0 297647 0 0 0 FREDERICK SIMPSON PHYSICIAN 253650 0 0 0 40798 0 33750 0 33169 0 361367 0 0 0 KAREN SMITH PHYSICIAN 161403 0 0 0 133179 0 7289 0 33160 0 335031 0 0 0 RUDY BOHINE PHYSICIAN 183754 0 0 0 105609 0 0 0 13893 0 303256 0 0 0 PART I, LINE 1A THE HOSPITAL PAYS THE DUES FOR MR. BOECKER, THE PRESIDENT/CEO FOR THE PIQUA COUNTRY CLUB EACH YEAR. THE AMOUNT IS INCLUDED IN HIS TAXABLE SALARY. PART I, LINE 4B PAST CEO THOMAS BOECKER HAD ADDITIONAL W2 COMPENSATION OF $250,433 FOR 2014.THIS INCOME IS COMPENSATION THOMAS BOECKER HAD PRIOR REPORTED AS W2 INCOME AND INVESTED INTO A COMPANY SPONSORED 457(F) PLAN. BOARD RESOLUTION TERMINATED THE PLAN WHICH RESULTED IN PAYOUT OF INVESTMENT IN 2014 AND REPORTED AS 2014 INCOME. FRED HAUSSMAN MD FOR PREMIER HEALT HOSPITAL TRUSTEE IS EMPLOYEE OF PREMIER HEALTHCARE 463464 ER PHYSICIAN SERVICES 0 SONDRA BOECKER MARRIED TO CEO 22784 SALARY 0 DAN BENSMAN HOSPITAL TRUSTEE IS PARTNER IN FAULKNER, GARMHAUSEN, KEISTER & SHENK 35610 LEGAL SERVICES 0 FORM 990, PART VI, SECTION B, LINE 11 THE RETURN WILL BE REVIEWED BY THE BOARD OF TRUSTEES PRIOR TO SUBMISSION. FORM 990, PART VI, SECTION B, LINE 12C ANY DUALITY OF INTEREST OR POSSIBLE CONFLICT OF INTEREST ON THE PART OF ANY GOVERNING BOARD MEMBER SHOULD BE DISCLOSED TO THE OTHER MEMBERS OF THE BOARD AND MADE A MATTER OF RECORD, EITHER THROUGH THE ANNUAL PROCEDURE OR WHEN THE INTEREST BECOMES A MATTER OF BOARD ACTION. ANY GOVERNING BOARD MEMBER HAVING A DUALITY OF INTEREST OR POSSIBLE CONFLICT OF INTEREST ON ANY MATTER SHOULD NOT VOTE OR USE HIS PERSONAL INFLUENCE ON THE MATTER, AND THE PERSON SHALL NOT BE COUNTED IN DETERMINING THE QUORUM OF THE MEETING. THE MINUTES OF THE MEETING SHALL REFLECT THAT A DISCLOSURE WAS MADE, THE ABSTENTION FROM VOTING, AND THE QUORUM SITUATION. FORM 990, PART VI, SECTION B, LINE 15 THE HR COMMITTEE OF THE BOARD CONDUCTS AN ANNUAL EVALUATION PROCESS INVOLVING INPUT FROM BOARD MEMBER, SENIOR MANAGERS AND MEDICAL STAFF. COMPENSATION IS BENCHMARKED WITH SURVEYS FROM LIKE SIZED HEALTHCARE ORGANIZATIONS. THE BOARD OF TRUSTEES APPROVES THE CEO COMPENSATION PACKAGE ANNUALLY. FORM 990, PART VI, SECTION C, LINE 19 THE DOCUMENTS ARE MADE AVAILABLE UPON REQUEST. FORM 990, PART IX, LINE 11G PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 6,463,728. MANAGEMENT AND GENERAL EXPENSES 900,665. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 7,364,393. PHYSICIAN AND PROVIDER REMUNERATION: PROGRAM SERVICE EXPENSES 3,575,096. MANAGEMENT AND GENERAL EXPENSES 498,159. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 4,073,255. MAINTENANCE CONTRACTS: PROGRAM SERVICE EXPENSES 2,288,030. MANAGEMENT AND GENERAL EXPENSES 318,817. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,606,847. FORM 990, PART XI, LINE 9: TRANSFERS -150,562. NET ASSETS RELEASED FROM RESTRICTION 549,751. FORM 990, PART XII, LINE 2C: THE COMMITTEE THAT ASSUMES RESPONSIBLITY FOR OVERSIGHT OF THE AUDIT OF THE FINANCIAL STATEMENTS AND SELECTION OF THE INDEPENDENT ACCOUNTANT DID NOT CHANGE ITS OVERSIGHT PROCESS OR SELECTION PROCESS DURING THE CURRENT TAX YEAR. WILSON CARE LLC 915 W MICHIGAN STREET SIDNEY OH 45365 341734715 PHYSICIAN OFFICES OH -1549006 3933120 WILSON MEMORIAL HOSPITAL WILSON MEMORIAL HOSPITAL FOUNDATION 915 WEST MICHIGAN STREET SIDNEY OH 45365 521771615 SUPPORTING HOSPITAL ACTIVITIES OH 501(C)(3) LINE 11A, I N/A 0 SLEEP LAB LLC 915 WEST MICHIGAN STREET SIDNEY OH 45365 OH SHELBY COUNTY MEMORIAL HOSPITAL RELATED 238833 178913 0 0 0.60000 1 1 1 0 0 0 0 0 0 1 0 0 1 1 1 1 1 1 1 SLEEP LAB LLC J 23327 CASH