2015-01-26T12:35:18-06:00 2014-06-30 351178661 BLUE & CO LLC ONE AMERICAN SQUARE 2200 INDIANAPOLIS IN 46282 990 2013-07-01 350811197 FAIRBANKS HOSPITAL INC FAIR 3178498222 8102 CLEARVISTA PARKWAY INDIANAPOLIS IN 46256 BARBARA ELLIOTT INTERIM PRESIDENT AND CEO 3175729450 2015-01-26 1 AMBER KOCHER CPA P01286298 3176334705 2013 2016-04-25 22:37:26Z BARBARA ELLIOTT 8102 CLEARVISTA PARKWAY INDIANAPOLIS IN 46256 21800830 0 X WWW.FAIRBANKSCD.ORG X 1946 IN NONPROFIT ORGANIZATION FOCUSED ON RECOVERY FROM ALCOHOL AND OTHER DRUG PROBLEMS. 17 16 347 150 0 0 3079335 965897 17927665 18955859 31015 -51231 1452082 1699189 22490097 21569714 0 599340 0 0 13568081 14183709 0 0 201625 5792382 6276348 19360463 21059397 3129634 510317 26743154 27226497 1900664 2011444 24842490 25215053 X FAIRBANKS IS A NONPROFIT ORGANIZATION FOCUSED ON RECOVERY FROM ALCOHOL AND OTHER DRUG PROBLEMS, SERVING AS A RESOURCE TO IMPROVE THE WELL-BEING OF INDIVIDUALS, FAMILIES AND COMMUNITIES BY OFFERING HOPE AND SUPPORT THROUGH ITS PROGRAMS AND SERVICES. 0 0 8484388 0 9749197 ADULT INPATIENT SERVICES CONSISTING OF DETOXIFICATION, REHABILITATION AND RESIDENTIAL SERVICES. THE DETOXIFICATION PHASE IS A MEDICALLY MANAGED LEVEL OF CARE WHERE THE EXTENT OF THE PATIENT'S ADDICTION IS DETERMINED AND THE PHYSICAL AND PSYCHOLOGICAL IMPACT OF THAT ADDICTION IS ASSESSED AND THE APPROPRIATE TREATMENT COURSE IS INITIATED. FOR THE CURRENT FISCAL YEAR, FAIRBANKS HOSPITAL HAD 8,978 ADULT DETOX PATIENT DAYS.THE REHABILITATION PHASE OCCURS WHEN FURTHER INPATIENT STABILIZATION/TREATMENT IS NEEDED AND REQUIRES CONTINUED MEDICAL SUPERVISION. THE TREATMENT PROCESS IS MULTI-DISCIPLINARY AND GROUP ORIENTED. FOR THE CURRENT FISCAL YEAR, THE HOSPITAL HAD 2,456 ADULT REHAB PATIENT DAYS. THE RESIDENTIAL PROGRAM IS FOR THE PATIENT WHO REQUIRES A RESTRICTIVE ENVIRONMENT TO ABSTAIN FROM USING BUT WHO IS MEDICALLY STABLE. THE PATIENT PARTICIPATES IN NO LESS THAN FOUR HOURS OF THERAPY DAILY AND NURSING CARE IS PROVIDED, IF NEEDED. FOR THE CURRENT FISCAL YEAR, THE HOSPITAL HAD 916 ADULT RESIDENTIAL PATIENT DAYS. 3338891 0 3836635 ADULT OUTPATIENT SERVICES PROGRAM CONSISTING OF PARTIAL HOSPITALIZATION (PHP) AND INTENSIVE OUTPATIENT PROGRAM (IOP). THE PHP PROGRAM IS SIX TO SEVEN HOURS PER DAY MONDAY THROUGH FRIDAY AND IS A MULTI-DISCIPLINARY AND GROUP ORIENTED TREATMENT PROGRAM. IT WILL CONTAIN EVALUATION AND EDUCATION. IT ALLOWS THE PATIENT TO EXPERIENCE LIFE ON THE "OUTSIDE" WHILE BEING INVOLVED IN A VERY INTENSE LEVEL OF TREATMENT. FOR THE CURRENT FISCAL YEAR, THE HOSPITAL HAD 7,844 PHP VISITS.IOP IS AVAILABLE TO THOSE WHOSE ADDICTION IS NOT SO SEVERE AS TO REQUIRE INPATIENT OR PHP SERVICES. THE PATIENTS MUST DEMONSTRATE THE ABILITY TO REMAIN DRUG-FREE DURING THE ENTIRE TREATMENT COURSE AND INDICATE A WILLINGNESS TO BECOME INVOLVED IN A 12-STEP PROGRAM. IOP PATIENTS GENERALLY MEET FOR THREE HOURS, THREE TIMES PER WEEK. IOP OFFERS EDUCATION AND GROUP THERAPY. FOR THE CURRENT FISCAL YEAR, THE HOSPITAL HAD 11,305 VISITS. 1150303 1321785 ADOLESCENT INPATIENT SERVICES CONSISTING OF DETOXIFICATION, REHABILITATION, AND RESIDENTIAL SERVICES. THE DETOXIFICATION PHASE IS A MEDICALLY MANAGED LEVEL OF CARE WHERE THE EXTENT OF THE PATIENT'S ADDICTION IS DETERMINED AND THE PHYSICAL AND PSYCHOLOGICAL IMPACT OF THAT ADDICTION IS ASSESSED AND THE APPROPRIATE TREATMENT COURSE IS INITIATED. ADOLESCENT GUIDANCE SPECIALISTS ARE MEMBERS OF THE TREATMENT TEAM. DURING THIS PHASE OF CARE, VARIOUS MULTI-DISCIPLINARY EVALUATIONS ARE COMPLETED. FAMILIES AND OTHER SUPPORT INDIVIDUALS (SCHOOL, PROBATION, CASEWORKERS, ETC) ARE INVOLVED. FOR THE CURRENT FISCAL YEAR, FAIRBANKS HOSPITAL HAD 519 ADOLESCENT DETOX PATIENT DAYS.THE ADOLESCENT REHAB PHASE IS FOR PATIENTS NEEDING FURTHER INPATIENT STABILIZATION/TREATMENT AND REQUIRES MEDICAL SUPERVISION. THIS TREATMENT PROCESS IS MULTI-DISCIPLINARY AND GROUP ORIENTED. AN IMPORTANT PART OF THE PROGRAM INCLUDES FAMILY MEMBERS OF THE PATIENT. FOR THE CURRENT FISCAL YEAR, THE HOSPITAL HAD 636 ADOLESCENT REHAB PATIENT DAYS.THE RESIDENTIAL PHASE IS FOR ADOLESCENTS IN NEED OF STABILIZATION AND TREATMENT. TREATMENT IS MULTI-DISCIPLINARY AND GROUP-ORIENTED. ADOLESCENTS RECEIVE INFORMATION ON DEVELOPING SOCIAL SKILLS, COMMUNICATION, HOW TO GAIN INTERNAL CONTROL OVER FEELING, HOW TO DEAL WITH ANGER, HOW TO DEAL WITH PEER PRESSURE, AND OTHER DEVELOPMENT NEEDS. FOR THE CURRENT FISCAL YEAR, THE HOSPITAL HAD 1,323 ADOLESCENT RESIDENTIAL PATIENT DAYS. 4244863 599340 4877666 OTHER PROGRAM SERVICES INCLUDING YOUNG ADULT INPATIENT SERVICES AND ADOLESCENT OUTPATIENT SERVICES.YOUNG ADULT INPATIENT SERVICES CONSISTING OF DETOXIFICATION, REHABILITATION, AND RESIDENTIAL SERVICES FOR MALES BETWEEN THE AGES OF 19-23. THE DETOXIFICATION PHASE IS A MEDICALLY MANAGED LEVEL OF CARE WHERE THE EXTENT OF THE PATIENT'S ADDICTION IS DETERMINED AND THE PHYSICAL AND PSYCHOLOGICAL IMPACT OF THAT ADDICTION IS ASSESSED AND THE APPROPRIATE TREATMENT COURSE IS INITIATED. YOUNG ADULT GUIDANCE SPECIALISTS ARE MEMBERS OF THE TREATMENT TEAM. DURING THIS PHASE OF CARE, VARIOUS MULTI-DISCIPLINARY EVALUATIONS ARE COMPLETED. FAMILIES AND OTHER SUPPORT INDIVIDUALS (SCHOOL, PROBATION, CASEWORKERS, ETC) ARE INVOLVED. FOR THE CURRENT FISCAL YEAR, FAIRBANKS HOSPITAL HAD 470 YOUNG ADULT DETOX PATIENT DAYS. THE YOUNG ADULT REHAB PHASE IS FOR PATIENTS NEEDING FURTHER INPATIENT STABILIZATION/TREATMENT AND REQUIRE MEDICAL SUPERVISION. THIS TREATMENT PROCESS IS MULTI-DISCIPLINARY AND GROUP ORIENTED. AN IMPORTANT PART OF THE PROGRAM INCLUDES FAMILY MEMBERS OF THE PATIENT. FOR THE CURRENT FISCAL YEAR, THE HOSPITAL HAD 326 YOUNG ADULT REHAB PATIENT DAYS.THE RESIDENTIAL PHASE IS FOR YOUNG ADULTS IN NEED OF STABILIZATION AND TREATMENT. TREATMENT IS MULTI-DISCIPLINARY AND GROUP ORIENTED. YOUNG ADULTS RECEIVE INFORMATION ON DEVELOPING SOCIAL SKILLS, COMMUNICATION, HOW TO GAIN INTERNAL CONTROL OVER FEELING, HOW TO DEAL WITH ANGER, HOW TO DEAL WITH PEER PRESSURE, AND OTHER DEVELOPMENT NEEDS. FOR THE CURRENT FISCAL YEAR, THE HOSPITAL HAD 382 YOUNG ADULT RESIDENTIAL PATIENT DAYS.ADOLESCENT OUTPATIENTS SERVICES PROGRAM SERVED 1,715 PHP VISITS AND 2,381 IOP VISITS DURING THE CURRENT FISCAL YEAR. YOUNG ADULT OUTPATIENT SERVICES PROGRAM SERVED 644 PHP VISITS AND 1,472 IOP VISITS DURING THE CURRENT FISCAL YEAR. ADULT HALFWAY HOUSE SERVED 937 PATIENT DAYS DURING THE CURRENT FISCAL YEAR. FAIRBANKS HOSPITAL PROVIDED 3,018 PATIENT DAYS AT LAVERNA LODGE FOR MEN,1,065 PATIENT DAYS AT LAVERNA LODGE FOR WOMEN, AND 31,194 PATIENT DAYS AT SUPPORTED LIVING FACILITIES DURING THE CURRENT FISCAL YEAR. 4244863 599340 4877666 17218445 1 1 0 0 0 0 0 0 0 1 1 0 0 0 1 1 0 1 0 0 0 0 0 0 1 0 1 1 1 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 1 1 0 0 0 1 31 0 1 347 1 0 0 0 0 0 1 1 0 0 0 0 X 17 16 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 0 0 IN X BARBARA ELLIOTT INTERIM PRESIDENT AND CEO 3175729450 8102 CLEARVISTA PARKWAY INDIANAPOLIS IN 46256 X RICHARD COLLINS CHAIRMAN 1.00 0.00 X X 0 0 0 TOM FLOWERS VICE CHAIR 1.00 0.00 X X 0 0 0 KEVIN MURPHY TREASURER 1.00 0.00 X X 0 0 0 FARAZ ABBASI SECRETARY 1.00 0.00 X X 0 0 0 CAROL BROWN LUKEMEYER BOARD MEMBER 1.00 0.00 X 0 0 0 PATRICK CARR BOARD MEMBER 1.00 0.00 X 0 0 0 DAVID CORBITT BOARD MEMBER 1.00 0.00 X 0 0 0 JOHN HAYES MD BOARD MEMBER 1.00 0.00 X 0 0 0 MARISSA MANLOVE BOARD MEMBER 1.00 0.00 X 0 0 0 ANN MERKEL BOARD MEMBER 1.00 0.00 X 0 0 0 BEVERLY PITTS BOARD MEMBER 1.00 0.00 X 0 0 0 SENATOR PAT MILLER BOARD MEMBER 1.00 0.00 X 0 0 0 KARL STOUT BOARD MEMBER 1.00 0.00 X 0 0 0 ANDRIAN TAKACS BOARD MEMBER 1.00 0.00 X 0 0 0 JOHN WANTZ BOARD MEMBER 1.00 0.00 X 0 0 0 JANE WARDLE BOARD MEMBER 1.00 1.00 X 0 0 0 THOMAS CRAIG TERM END 4'14 TREASURER 1.00 0.00 X X 0 0 0 TOM EMMERSON RESIGNED 4'14 BOARD MEMBER 1.00 0.00 X 0 0 0 LUKE KENLEY TERM END 4'14 BOARD MEMBER 1.00 0.00 X 0 0 0 PEGGY MAGEE RESIGNED 4'14 BOARD MEMBER 1.00 0.00 X 0 0 0 MARK MONSON PRESIDENT/CEO 38.40 1.60 X X 178089 0 23587 BARBARA ELLIOTT VICE PRESIDENT AND CFO 36.00 4.00 X 125829 0 30378 TIMOTHY KELLY RESIGNED 6'14 MEDICAL DIRECTOR 32.00 0.00 X 188521 0 27938 DR DENNIS RHYNE PHYSICIAN 40.00 0.00 X 221196 0 21116 DR ANDREW SONDERMAN PHYSICIAN 40.00 0.00 X 158085 0 23413 JENNIFER HORSTMAN CNO/CIO 40.00 0.00 X 101386 0 13630 SHARON BAKER DIRECTOR OF SUPPORT SERVICES 40.00 0.00 X 101350 0 7828 1074456 0 147890 7 0 1 0 FA WILHELM CONSTRUCTION COMPANY PO BOX 516 INDIANAPOLIS IN 46206 CONSTRUCTION SERVICES 2041837 SODEXO INC & AFFILIATES 4880 PAYSPHERE CIRCLE CHICAGO IL 60674 FOOD SERVICES MGMT 869405 NETSMART TECHNOLOGIES PO BOX 823519 PHILADELPHIA PA 19182 SOFTWARE IMPLEMENTATION AND SUPPORT 330258 SOUTH BEND MEDICAL FOUNDATION PO BOX 2030 MISHAWAKA IN 46546 REFERRAL LAB SERVICE 306884 PROGRESSIVE HOMECARE SERVICES PO BOX 6069-DEPT 178 INDIANAPOLIS IN 46206 PHARMACY SERVICES 280287 11 75877 258714 631306 965897 PATIENT SERVICE REVENUE 621300 18955859 18955859 18955859 64927 64927 144605 0 144605 144605 144605 116158 -116158 -116158 -116158 67360 75877 114958 -47598 -47598 1696 0 1696 1696 EHR INCENTIVE 900099 404531 404531 OUTSIDE COUNSELING SERVICES 624100 280288 280288 GIFT SHOP REVENUE 453220 57307 57307 858360 858360 1600486 21569714 19785283 0 818534 599340 599340 689896 207216 482680 9879841 8298361 1453221 128259 333673 280261 49080 4332 2431309 2046166 354331 30812 848990 713091 124878 11021 66396 66396 55479 55479 9604 9604 1934845 1372479 556478 5888 354765 342150 12065 550 147197 99818 46855 524 1228678 1167690 60988 52026 50133 1771 122 52552 21484 30149 919 14005 14005 1028674 949945 78729 292918 228974 63944 SUPPLIES 643029 625299 17499 231 EQUIPMENT MAINTENANCE A 94809 83671 11138 PRINTING AND PUBLICATIO 53518 20838 27299 5381 POSTAGE AND SHIPPING 23757 12043 9104 2610 224096 75877 137243 10976 21059397 17218445 3639327 201625 1806354 153554 6984631 3580953 92363 1536 3167912 4511593 533664 638141 22708491 9390497 13595908 13317994 4847866 562322 174860 26743154 27226497 1205997 1327088 490000 450000 204667 234356 1900664 2011444 X 24618944 25030187 223546 184866 24842490 25215053 26743154 27226497 X 510317 116027 -253781 X X 0 1 X 1 1 1 X SCHEDULE A, PART I, LINE3: FAIRBANKS HOSPITAL, INC. HAS BEEN DETERMINED BY THE IRS TO BE A PUBLIC CHARITY UNDER IRS CODE SECTION 170(B)(1)(A)(III). PER SCHEDULE H INSTRUCTIONS ONLY ORGANIZATIONS THAT OPERATE AT LEAST ONE FACILITY THAT IS, OR IS REQUIRED TO BE, LICENSED, REGISTERED, OR SIMILARLY RECOGNIZED BY A STATE AS A HOSPITAL IS REQUIRED TO COMPLETE THIS SCHEDULE. FAIRBANK HOSPITAL, INC. IS A PRIVATE MENTAL HEALTH INSTITUTION AND CERTIFIED AS AN ADDICTIONS SERVICE PROVIDER. FAIRBANKS HOSPITAL IS NOT LICENSED BY THE INDIANA STATE DEPARTMENT OF HEALTH AS A HOSPITAL, BUT IS RECOGNIZED BY THE CENTERS FOR MEDICAID AND MEDICARE AS AN ACUTE CARE HOSPITAL. THE COMPLETION OF SCHEDULE H IS NOT REQUIRED; HOWEVER, FAIRBANKS' MANAGEMENT HAS DECIDED TO COMPLETE SCHEDULE H TO PROVIDE INFORMATION TO THE COMMUNITY REGARDING ITS FINANCIAL ASSISTANCE, COMMUNITY BENEFITS, AND FACILITY INFORMATION. RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 898546 405239 442444 861341 924344 2368777 2394575 898546 873382 440636 429 390103 924344 892895 391777 5733 417023 873382 979700 732482 47932 867219 892895 0.78540 0.00000 0.21460 0 0 792514 792514 14963183 5383520 9579663 6952794 4006977 2945817 13317994 ESTIMATED THIRD PARTY SETTLEMENTS 234356 234356 X 21800699 116027 114958 230985 21569714 0 21569714 21174355 114958 114958 21059397 0 21059397 PART V, LINE 4: TEMPORARILY RESTRICTED NET ASSETS ARE THOSE ASSETS WHOSE USE HAS BEEN LIMITED BY DONORS FOR A SPECIFIC OPERATING OR CAPITAL PURPOSE. BOARD DESIGNATED FUNDS ARE SET ASIDE BY THE BOARD FOR SPECIFIC PURPOSES INCLUDING CHARITY CARE. PART X, LINE 2: ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA REQUIRE MANAGEMENT TO EVALUATE TAX POSITIONS TAKEN BY FAIRBANKS AND THE SCHOOL AND RECOGNIZE A TAX LIABILITY IF FAIRBANKS OR THE SCHOOL 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 FAIRBANKS AND THE SCHOOL, AND HAS CONCLUDED THAT AS OF JUNE 30, 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. PART XI, LINE 2D - OTHER ADJUSTMENTS: FUNDRAISING EVENT ACTIVITY 114,958. PART XII, LINE 2D - OTHER ADJUSTMENTS: FUNDRAISING EVENT ACTIVITY 114,958. CIRCLE OF HOPE DINNER 124357 64037 60320 9462 34751 25000 34951 ALUMNI GOLF OUTING 18880 11840 7040 718 7401 2675 143237 75877 67360 718 16863 34751 25000 37626 114958 -47598 1 1 0 1 X 0 1 0 1 0 823085 823085 0.03910 283699 87111 196588 0.00930 1106784 87111 1019673 0.04840 972664 4655 968009 0.04600 76955 76955 0.00370 1049619 4655 1044964 0.04970 2156403 91766 2064637 0.09810 1 2190426 0 2365536 2267058 98478 X 1 1 1 1 FAIRBANKS HOSPITAL INC 8102 CLEARVISTA PARKWAY INDIANAPOLIS IN 46256 WWW.FAIRBANKSCD.ORG X LICENSED PRIVATE MENTAL HEALTH INSTITUTION FAIRBANKS HOSPITAL INC 1 1 X X X X X X X X 12 1 0 1 X HTTP://WWW.FAIRBANKSCD.ORG/ABOUT-FAIRBANK X X X X X X 0 0 1 0 1 250.000000000000 1 X X X X X 1 1 X X X X 1 0 X X X X 0 X X 0 0 FAIRBANKS HOSPITAL, INC PART V, SECTION B, LINE 3: IN CONDUCTING ITS MOST RECENT CHNA THE HOSPITAL TOOK INTO ACCOUNT INPUT FROM PERSONS WHO REPRESENTED THE COMMUNITY IT SERVED INCLUDING THOSE WITH SPECIAL KNOWLEDGE THROUGH FIVE FOCUS GROUPS. THE GROUPS WERE DETERMINED THROUGH DISCUSSION WITH ACADEMIC AND HEALTHCARE EXPERTS WHO HAVE KNOWLEDGE OF THE SUBSTANCE IMPACTED POPULATION IN THE INDIANAPOLIS METROPOLITAN AREA. THE FIRST GROUP CONSISTED OF ADDICTION SERVICE PROVIDERS FOR LOW INCOME AND MINORITY POPULATIONS; THE SECOND GROUP WAS COMPOSED OF COMMUNITY STAKEHOLDERS FROM THE STATE CRIMINAL JUSTICE DEPARTMENT, TASK FORCE ON DRUG FREE MARION COUNTY, HALFWAY HOUSES, PRIMARY MEDICAL CARE COALITION, AND EMPLOYEE ASSISTANCE PROGRAMS. ADOLESCENTS ATTENDING THE RECOVERY HIGH SCHOOL COMPRISED THE THIRD GROUP; PARENTS OF ADOLESCENTS WHO HAD RECEIVED ADDICTION TREATMENT SERVICES WERE IN THE FOURTH, AND THE FIFTH GROUP CONSISTED OF ADULT PATIENTS WHO HAD SUCCESSFULLY COMPLETED INPATIENT TREATMENT. FOCUS GROUP QUESTIONS INCLUDED IDENTIFICATION OF STRENGTHS AND WEAKNESSES IN THE ADDICTION TREATMENT SYSTEM, BARRIERS TO SERVICES, GAPS IN SERVICES, AND RECOMMENDATIONS FOR THE SYSTEM OF CARE. FAIRBANKS HOSPITAL, INC PART V, SECTION B, LINE 5D: THE HOSPITAL FACILITY'S CHNA IS AVAILABLE TO THE PUBLIC ON THE HOSPITAL'S WEBSITE AT WWW.FAIRBANKSCD.ORG UNDER "ABOUT US" AND CLICK ON "SEE OUR MOST RECENT COMMUNITY NEEDS ASSESSMENT" OR ENTER THE FOLLOWING WEB ADDRESS INTO THE BROWSER: HTTP://WWW.FAIRBANKSCD.ORG/FILES/COMMUNITY%20NEEDS%20ASSESSMENT.PPT FAIRBANKS HOSPITAL, INC PART V, SECTION B, LINE 6I: FAIRBANKS HOSPITAL COMPLETED THEIR FISCAL YEAR 2013 COMMUNITY NEEDS ASSESSMENT IN JUNE 2013. THE ASSESSMENT CONTAINED NINE STRATEGIES OF WHICH SIX STRATEGIES HAVE BEEN ACCOMPLISHED THROUGH DECEMBER 2014. THE REMAINING STRATEGIES ARE COLLABORATIVE IN NATURE AND REQUIRE COMPREHENSIVE PLANNING. THE GOAL IS TO COMPLETE THE REMAINING THREE STRATEGIES OVER THE NEXT 18 MONTHS. FAIRBANKS HOSPITAL, INC PART V, SECTION B, LINE 20D: FAIRBANKS OFFERS A 40% STANDARD DISCOUNT FOR SELF PAY INDIVIDUALS WITHOUT A THIRD PARTY PAYMENT SOURCE OR TO PATIENTS WHO EXHAUST THEIR THIRD PARTY BENEFTIS AND BECOME SELF-PAY; 50% DISCOUNT IS AVAILABLE WITH PROMPT PAY. 5 LAVERNA LODGE 8102 CLEARVISTA PARKWAY INDIANAPOLIS IN 46256 DRUG & ALCOHOL RESIDENTIAL REHAB - SEPARATE LOCATION FOR MEN & WOMEN SUPPORTED LIVING PROGRAM 8102 CLEARVISTA PARKWAY INDIANAPOLIS IN 46256 ADULT HALFWAY HOUSE & DRUG & ALCOHOL SUPPORTED LIVING KOKOMO ADDICTIONS TREATMENT CENTER 210 W WALNUT STREET STE 258 261 KOKOMO IN 46901 OUTPATIENT CENTER PLAINFIELD ADDICTIONS TREATMENT FACILITY 6100 CLARKS CREEK RD STE 102 104 PLAINFIELD IN 46168 OUTPATIENT CENTER PART I, LINE 7: FAIRBANKS USES THE IRS WORKSHEETS PROVIDED IN THE INSTRUCTIONS FOR FORM 990, SCHEDULE H TO CALCULATE A SINGLE COST TO CHARGE RATIO WHICH IS APPLIED TO THE CHARGES FOR FINANCIAL ASSISTANCE AND OTHER BENEFITS TO PROVIDE AMOUNTS AT COST. PART I, LN 7 COL(F): EFFECTIVE JULY 1, 2012, FAIRBANKS ADOPTED ACCOUNTING STANDARDS UPDATE (ASU)2011-07, HEALTHCARE ENTITIES (TOPIC 954), "PRESENTATION AND DISCLOSURE OF PATIENT SERVICE REVENUE, PROVISION FOR BAD DEBTS, AND THE ALLOWANCE FOR DOUBTFUL ACCOUNTS FOR CERTAIN HEALTHCARE ENTITIES," WHICH REQUIRES CERTAIN HEALTHCARE ENTITIES TO PRESENT THE PROVISION FOR BAD DEBTS RELATING TO PATIENT SERVICE REVENUE AS A DEDUCTION FROM PATIENT SERVICE REVENUE IN THE CONSOLIDATED STATEMENTS OF OPERATIONS AND CHANGES IN NET ASSETS RATHER THAN AS AN OPERATING EXPENSE. ADOPTION OF THIS STANDARD HAS NO IMPACT ON ITS FINANCIAL POSITION, RESULTS OF OPERATIONS, OR CASH FLOWS. PART III, LINE 2: BAD DEBT EXPENSE METHODOLOGY: THE AMOUNT OF BAD DEBT HAS BEEN PROVIDED FROM THE AUDITED FINANCIAL STATEMENTS. PART III, LINE 3: EXPLANATION FOR RATIONAL FOR INCLUDING OTHER BAD DEBT AMOUNT IN COMMUNITY BENEFIT: NO OTHER BAD DEBT AMOUNTS HAVE BEEN INCLUDED AS COMMUNITY BENEFIT. THE HOSPITAL HAS A DETAILED FINANCIAL ASSISTANCE POLICY WHICH STATES THAT TO PARTICIPATE IN CHARITY CARE, CANDIDATES MUST PROVIDE NECESSARY INFORMATION WITHIN 15 DAYS OF ADMISSION. IN ADDITION, THE HOSPITAL EDUCATES PATIENTS WITH LIMITED ABILITY TO PAY REGARDING FINANCIAL ASSISTANCE. FOR THIS REASON, THE ORGANIZATION BELIEVES IT ACCURATELY CAPTURES ALL CHARITY CARE DEDUCTIONS PROVIDED ACCORDING TO THE FINANCIAL ASSISTANCE POLICY AND THE AMOUNT OF BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY IS NEGLIGIBLE. PART III, LINE 4: BAD DEBT EXPENSE FOOTNOTE TO AUDITED FINANCIAL STATEMENTS IS LOCATED ON PAGES 7 AND 8 OF THE ATTACHED AUDITED FINANCIAL STATEMENTS UNDER THE HEADING "ALLOWANCE FOR DOUBTFUL ACCOUNTS". PART III, LINE 8: MEDICARE ALLOWABLE COSTS ARE CALCULATED BY USING THE RATIO OF COST TO CHARGES. 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, 2014: HOSPITAL STATEMENT OF REIMBURSABLE COST. PART III, LINE 9B: WHEN AN ACCOUNT IS IDENTIFIED AS UNCOLLECTIBLE, IT BECOMES BAD DEBT. IF THE FINANCIAL POSITION OF THE IDENTIFIED INDIVIDUAL'S ACCOUNT HAS BEEN VERIFIED AS BEING IN A FINANCIAL POSITION OF 250% FEDERAL POVERTY LEVEL, THE ACCOUNT WILL BE RECLASSED AS CHARITY CARE. PART VI, LINE 2: FAIRBANKS ENGAGED THE SERVICES OF THE INDIANA UNIVERSITY CENTER FOR HEALTH POLICY TO CONDUCT COMMUNITY FOCUS GROUPS. THE GROUPS WERE DETERMINED THROUGH DISCUSSION WITH ACADEMIC AND HEALTHCARE EXPERTS WHO HAVE KNOWLEDGE OF THE SUBSTANCE IMPACTED POPULATION IN THE INDIANAPOLIS METROPOLITAN AREA. FIVE SEPARATE FOCUS GROUPS WERE DEVELOPED. THE FIRST GROUP CONSISTED OF ADDICTION SERVICE PROVIDERS FOR LOW INCOME AND MINORITY POPULATIONS; THE SECOND GROUP WAS COMPOSED OF COMMUNITY STAKEHOLDERS FROM THE STATE CRIMINAL JUSTICE DEPARTMENT, TASK FORCE ON DRUG FREE MARION COUNTY, HALFWAY HOUSES, PRIMARY MEDICAL CARE COALITION, AND EMPLOYEE ASSISTANCE PROGRAMS. ADOLESCENTS ATTENDING THE RECOVERY HIGH SCHOOL COMPRISED THE THIRD GROUP; PARENTS OF ADOLESCENTS WHO HAD RECEIVED ADDICTION TREATMENT SERVICES WERE IN THE FOURTH, AND THE FIFTH GROUP CONSISTED OF ADULT PATIENTS WHO HAD SUCCESSFULLY COMPLETED INPATIENT TREATMENT. FOCUS GROUP QUESTIONS INCLUDED IDENTIFICATION OF STRENGTHS AND WEAKNESSES IN THE ADDICTION TREATMENT SYSTEM, BARRIERS TO SERVICES, GAPS IN SERVICES, AND RECOMMENDATIONS FOR THE SYSTEM OF CARE. PART VI, LINE 3: THOSE INDIVIDUALS SEEKING ADMISSION TO FAIRBANKS HAVE THE OPPORTUNITY TO MEET WITH A FINANCIAL COUNSELOR TO DETERMINE WHAT RESOURCES ARE AVAILABLE. IN ADDITION, AN INFORMATION BOOKLET IS GIVEN TO THE FAMILIES DURING THE ADMISSION PROCESS WHICH NOTES THAT CHARITY CARE IS AVAILABLE. LASTLY, SIGNS ARE VISIBLE TO PATIENTS IN THE ACCESS DEPARTMENT WHERE ADMISSIONS TAKE PLACE. FAIRBANKS USES THE LOCAL MEDICA TO ASSIST IN EDUCATING THE PUBLIC CONCERNING PREVENTION, INTERVENTION AND TREATMENT. ALSO, FAIRBANKS PARTICIPATES IN NATIONAL ALCHOHOL AWARENESS MONTH, RECOVERY MONTH COMMUNITY ACTIVITIES, AND PROVIDES COMMUNITY EDUCATION THROUGH THE SUSAN LI CONFERENCE. PART VI, LINE 4: FOR THE FISCAL YEAR ENDED JUNE 30, 2014, 19,394 PERSONS WERE SERVED; 57% FROM UNITED WAY OF CENTRAL INDIANA COUNTIES, 20% SURROUNDING COUNTIES, 21% REMAINING INDIANA COUNTIES, AND 2% OUT OF STATE. PART VI, LINE 5: THE ORGANIZATION FURTHERS ITS EXEMPT PURPOSE BY PROMOTING HEALTH OF THE COMMUNITY THROUGH THE FOLLOWING: THE ORGANIZATION'S GOVERNING BODY IS COMPRISED OF A MAJORITY OF INDEPENDENT PERSONS WHO RESIDE IN THE ORGANIZATION'S PRIMARY SERVICE AREA. SURPLUS OF FUNDS WHEN AVAILABLE ARE USED TO IMPROVE THE PATIENT CARE AND MEDICAL EDUCATION OF THE STAFF; AND A PERCENTAGE OF OPERATING INCOME IS RESTRICTED FOR PATIENT SCHOLARSHIP FUNDS. FAIRBANKS USES THE LOCAL MEDIA TO ASSIST IN EDUCATING THE PUBLIC CONCERNING PREVENTION, INTERVENTION AND TREATMENT. THE ORGANIZATION ALSO PARTICIPATES IN NATIONAL ALCOHOL AWARENESS MONTH, RECOVERY MONTH COMMUNITY ACTIVITIES AND PROVIDES COMMUNITY EDUCATION THROUGH THE SUSAN LI CONFERENCE. PART VI, LINE 6: N/A - ORGANIZATION IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM. 1 HOPE ACADEMY 8102 CLEARVISTA PARKWAY INDIANAPOLIS IN 46256 203094377 599340 COST DEBT FORGIVENESS GENERAL SUPPORT 1 0 PART I, LINE 2: THERE WERE NO GRANT FUNDS GREATER THAN $5,000 AWARDED DURING THE YEAR. ASSISTANCE WAS PROVIDED ONLY TO A 501(C)(3) PUBLIC CHARITY FOR GENERAL SUPPORT. X X X X 0 0 0 0 0 0 0 0 0 MARK MONSON PRESIDENT/CEO 178089 0 0 0 0 0 0 0 23587 0 201676 0 0 0 BARBARA ELLIOTT VICE PRESIDENT AND CFO 125829 0 0 0 0 0 7144 0 23234 0 156207 0 0 0 TIMOTHY KELLY RESIGNED 6'14 MEDICAL DIRECTOR 188521 0 0 0 0 0 10460 0 17478 0 216459 0 0 0 DR DENNIS RHYNE PHYSICIAN 221196 0 0 0 0 0 12136 0 8980 0 242312 0 0 0 DR ANDREW SONDERMAN PHYSICIAN 158085 0 0 0 0 0 0 0 23413 0 181498 0 0 0 SCHEDULE J, PART II MR. MARK MONSON IS COMPENSATED BY FAIRBANKS HOSPITAL, INC. FOR HIS DUTIES AS PRESIDENT/CEO OF THE HOSPITAL. A PORTION OF HIS COMPENSATION RECEIVED FROM FAIRBANKS HOSPITAL, INC. IS ALLOCATED TO HOPE ACADEMY FOR DUTIES PROVIDED. FOR FY 2014, 4% OF MR. MONSONS' HOURS (83 ANNUALLY) OR SALARIES AND BENEFITS TOTALING $8,067 ARE ALLOCATED TO HOPE ACACDEMY. MS. BARBARA ELLIOTT IS COMPENSATED FROM FAIRBANKS HOSPITAL, INC. FOR HER DUTIES AS VICE PRESIDENT AND CFO OF THE HOSPITAL. A PORTION OF HER COMPENSATION RECEIVED FROM FAIRBANKS HOSPITAL, INC. IS ALLOCATED TO HOPE ACADEMY FOR DUTIES PROVIDED. FOR FY 2014, 10% OF MS. ELLIOTT'S HOURS (208 ANNUALLY) OR SALARIES AND BENEFITS TOTALING $15,621 ARE ALLOCATED TO HOPE ACACDEMY. UNITED HEALTHCARE SEE PART V 2546231 PART V BELOW 0 KRIEG DEVAULT LLP SEE PART V 64293 PART V BELOW 0 SCH L, PART IV, BUSINESS TRANSACTIONS INVOLVING INTERESTED PERSONS: (A) NAME OF PERSON: UNITED HEALTHCARE(B) RELATIONSHIP BETWEEN INTERESTED PERSON AND ORGANIZATION:ENTITY OF WHICH TWO CURRENT OFFICERS SERVED AS BOARD MEMBERS FOR FAIRBANKS HOSPITAL(D) DESCRIPTION OF TRANSACTION: UNITED HEALTHCARE IS A THIRD PARTY INSURANCE PAYOR TO FAIRBANKS HOSPITAL(A) NAME OF PERSON: KRIEG DEVAULT, LLP(B) RELATIONSHIP BETWEEN INTERESTED PERSON AND ORGANIZATION:PARTNERSHIP OF WHICH A CURRENT PARTNER SERVES AS A BOARD MEMBER OF FAIRBANKS HOSPITAL(D) DESCRIPTION OF TRANSACTION: KRIEG DEVAULT, LLP PROVIDES LEGAL SERVICES TO FAIRBANKS HOSPITAL. THE TRANSACTION IS PAYMENT FOR LEGAL FEES DURING THE YEAR. FORM 990, PART VI, SECTION B, LINE 11 THE PROCESS OF REVIEWING THE FORM 990 INCLUDES A DETAILED REVIEW OF THE FORM 990 AND REQUIRED SCHEDULES BY THE CHIEF EXECUTIVE OFFICER, CHIEF FINANCIAL OFFICER, AND BOARD FINANCE COMMITTEE. EACH VOTING MEMBER OF THE GOVERNING BODY REVIEWS AND APPROVES THE FORM 990 AT THE BOARD OF DIRECTOR MEETING TAKING PLACE FOR THE 2013 TAX RETURN AT THE DECEMBER 2014 BOARD MEETING. FORM 990, PART VI, SECTION B, LINE 12C THE BOARD MEMBERS MUST COMPLETE A CONFLICT OF INTEREST FORM ANNUALLY. BOARD MEMBERS WHO HAVE A POTENTIAL FOR CONFLICT MUST RECUSE THEMSELVES FROM VOTING ON SUBJECTS THAT MIGHT POSE A CONFLICT. THE CORPORATE COMPLIANCE OFFICER REVIEWS ANY POTENTIAL CONFLICTS THAT ARE REPORTED. FORM 990, PART VI, SECTION B, LINE 15A ALL CURRENT MEMBERS OF THE BOARD OF DIRECTORS ARE GIVEN A WRITTEN EVALUATION FORM TO RATE THE CEO. ALL INFORMATION IS THEN COMPILED IN A FINAL REPORT AND PRESENTED BY THE BOARD CHAIR TO THE CEO. FOR COMPENSATION, WE COMPILE DATA PROVIDED BY OUR INDEPENDENT AUDITORS FROM THE INDIANA HOSPITAL ASSOCIATION, OTHER MENTAL HEALTH PROVIDERS, AND NAATP (NATIONAL ASSOCIATION OF ADDICTION TREATMENT PROVIDERS) TO ENSURE THE SALARY IS COMPETITIVE AND REASONABLE. MEMBERS OF THE EXECUTIVE COMPENSATION COMMITTEE OF THE BOARD OF DIRECTORS MEET TO DISCUSS AND REVIEW THE DATA AND MAKE A FINAL DECISION REGARDING COMPENSATION THAT IS THEN REVIEWED AND APPROVED BY THE EXECUTIVE COMMITTEE OF THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION C, LINE 19 SUMMARY FINANCIAL INFORMATION IS AVAILABLE ON THE ORGANIZATION'S WEBSITE, REPORTED IN THE ANNUAL REPORTS. DETAILED FINANCIAL INFORMATION, GOVERNING DOCUMENTS, AND CONFLICT OF INTEREST POLICY IS AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART VII, SECTION A, LINE 1A: RELATED ORGANIZATION HOURS MR. MARK MONSON IS COMPENSATED FROM FAIRBANKS HOSPITAL, INC. FOR HIS DUTIES AS PRESIDENT/CEO OF THE HOSPITAL. A PORTION OF HIS COMPENSATION RECEIVED FROM FAIRBANKS HOSPITAL, INC. IS ALLOCATED TO HOPE ACADEMY FOR DUTIES PROVIDED. FOR FY 14, 4% MR. MONSON'S HOURS (83 HOURS ANNUALLY) OR SALARIES AND BENEFITS TOTALING $8,067 ARE ALLOCATED TO HOPE ACADEMY. MS. BARBARA ELLIOTT IS COMPENSATED FROM FAIRBANKS HOSPITAL, INC. FOR FY 14, 10% OF HER HOURS (208 HOURS ANNUALLY) OR SALARIES AND BENEFITS TOTALING $15,621 ARE ALLOCATED TO HOPE ACADEMY. FORM 990, PART XI, LINE 9: NET ASSETS TRANSFERRED TO HOPE ACADEMY -253,781. FORM 990, PART XI, LINE 2C: AUDIT OVERSIGHT THE ORGANIZATION UTILIZES THE AUDIT AND FINANCE COMMITTEE OF THE BOARD OF DIRECTORS TO OVERSEE THE AUDIT PROCEDURES AND SELECTION OF THE INDEPENDENT ACCOUNTING FIRM. THE RECOVERY HIGH SCHOOL AT FAIRBANKS INC DBA HOPE ACADEMY 8102 CLEARVISTA PARKWAY INDIANAPOLIS IN 46256 203094377 CHARTER SCHOOL IN 501(C)(3) LINE 2 FAIRBANKS HOSPITAL INC 1 0 1 0 0 0 0 0 0 0 1 0 1 0 1 1 0 1 0 0 THE RECOVERY HIGH SCHOOL AT FAIRBANKS INC DBA HOPE ACADEMY B 853121 COST THE RECOVERY HIGH SCHOOL AT FAIRBANKS INC DBA HOPE ACADEMY J 144600 COST