2014-08-14T11:32:12-05:00 2013-09-30 351178661 BLUE & CO LLC ONE AMERICAN SQUARE 2200 INDIANAPOLIS IN 46282 990 2012-10-01 350900741 FAYETTE MEMORIAL HOSPITAL ASSOCIATION INC FAYE 7658255131 1941 VIRGINIA AVE CONNERSVILLE IN 47331 RANDALL WHITE 7658255131 2014-08-14 1 AMBER KOCHER CPA P01286298 3176334705 2012 2015-11-30 17:44:51Z FAYETTE REGIONAL HOSPITAL SYSTEM SERVES WHITEWATER VALLEY RANDALL WHITE 1941 VIRGINIA AVE CONNERSVILLE IN 47331 69166568 0 X WWW.FAYETTEREGIONAL.ORG X 1913 IN OUR VISION IS FOR OUR TEAM TO SERVE THE HEALTH NEEDS OF THE WHITEWATER VALLEY RESIDENTS BY PROVIDING COMPASSIONATE, HIGH QUALITY, COST EFFECTIVE CARE. FAYETTE REGIONAL HELATH SYSTEM (FRHS) IS COMMITTED TO THE HEALTHCARE THAT THE COMMUNITY WANTS AND DESERVES; ACHIEVING THIS GOAL BY CONTINUING TO PROVIDE A FULL CONTINUUM OF INPATIENT AND OUTPATIENT HEALTHCARE SERVICES TO CONNERSVILLE AND THE SURROUNDING AREA' RESIDENTS. AT FRHS, WE ARE COMMITTED TO PROVIDING THE CARE FOR THE NEEDS OF THE COMMUNITY THROUGHOUT ITS LIFETIME. FOUNDED IN 1913, FRHS HAS BEEN PROVIDING QUALITY AND COMPASSIONATE HEALTH CARE FOR OVER 100 YEARS. THE MAIN HOSPITAL IS LOCATED IN THE HEART OF CONNERSVILLE, INDIANA, WITH FACILITIES IN ONE ADDITIONAL COUNTY IN ORDER TO PROVIDE QUALITY SERVICES CLOSE TO HOME. THE EQUIPMENT AND FACILITIES ENABLES US TO LIVE OUR MISSION. 10 6 685 103 32620 13239 29930 359572 55778339 52665033 831204 2261556 2653870 2199710 59293343 57485871 129881 142504 0 0 29617348 31514493 0 0 0 28475698 24069976 58222927 55726973 1070416 1758898 56560397 62886645 28894609 33039767 27665788 29846878 FAYETTE REGIONAL HEALTH SYSTEM IS A MULTI-FACETED HEALTH CARE CENTER WHICH PROVIDES SAFE, ACCURATE AND COMPASSIONATE HEALTH CARE THROUGH SERVICE EXCELLENCE TO THE CITIZENS OF EAST CENTRAL INDIANA TO PROMOTE HEALING AND HEALTHY LIVING. 0 0 49234486 142504 52677461 THE HOSPITAL PROVIDES INPATIENT AND OUTPATIENT SERVICES AND ACUTE REHAB SERVICES. MEDICARE AND MEDICAID AMOUNTED TO APPROXIMATELY 73% OF TOTAL SERVICES PROVIDED BY THE HOSPITAL. UNINSURED CARE WAS APPROXIMATELY $1.7 MILLION, AS CALCULATED BY GROSS CHARGES, FOR THE YEAR ENDED SEPTEMBER 30, 2013. TOTAL COMMUNITY BENEFIT CONTRIBUTIONS ARE $142,504. 49234486 1 1 0 1 0 0 0 0 0 0 1 1 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1 1 0 0 0 1 95 0 1 685 1 1 1 0 0 0 0 0 0 0 0 0 X 10 6 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 IN X DEBRA MICHALEK 7658277989 1941 VIRGINIA AVENUE CONNERSVILLE IN 47331 LOUISE WHITAKER 1.00 1.00 X 7500 0 0 CHARLES BROCHIN 1.00 0.00 X 12000 0 0 JIM THOMAS 1.00 1.00 X 6000 0 0 ARLENE BLIVEN 1.00 0.00 X 7500 0 0 SANDRA CATES 1.00 0.00 X 6000 0 0 DR PETRONIO ILAGAN 40.00 0.00 X 284079 0 14284 JOEL LONG 1.00 0.00 X 6000 0 0 MALCOLM MILES 1.00 0.00 X 7500 0 0 MICHAEL ROWE MD 40.00 0.00 X 421841 0 13961 JAG PATEL MD 40.00 0.00 X 298548 0 12288 RANDALL WHITE 40.00 1.00 X X 273052 0 19207 GARY SMITH 40.00 0.00 X 152885 0 11386 BETH WAMPLER 40.00 0.00 X 168306 0 16036 RHONDA MCPHERSON 40.00 0.00 X 128009 0 7815 STEPHEN CASTLEMAN MD 40.00 0.00 X 390405 0 14246 JOHN LANDRY MD 40.00 0.00 X 293105 0 14715 STEVEN JOHNSON MD 40.00 0.00 X 291495 0 16303 HATEM DAJANI MD 40.00 0.00 X 287872 0 7800 CAROL HULETT MD 40.00 0.00 X 285523 0 2501 3327620 0 150542 33 0 1 0 AMERISOURCE-BERGEN 27550 NETWORK PLACE CHICAGO IL 60673 PHARMACEUTICAL SERVICES 1968835 KEY BENEFIT ADMINISTRATORS 8330 ALLISON POINTE TRAIL INDIANAPOLIS IN 46205 THIRD PARTY ADMINISTRATOR 908047 MEDICUS HOSPITALISTS SERVICES LLC 22 ROULSTON RD WINDHAM NH 03087 LOCUM TENENS SERVICE PROVIDER 904492 WEATHERBY LOCUMS INC PO BOX 972633 DALLAS TX 75392 LOCUM TENENS SERVICE PROVIDER 812280 PREFERRED EMERGENCY SPECIALISTS INC 7324 YANKEE RD STE B LIBERTY TOWNSHIP OH 45044 ER PHYSICIANS 632367 40 359572 359572 NET PATIENT REVENUE 900099 52665033 52665033 52665033 476256 476256 103301 58253 45048 45048 12428 32620 13398177 9567 11599844 22600 1798333 -13033 1785300 1785300 EHR INCENTIVE PROGRAM 900099 1077594 1077594 BILLING SERVICES 900099 288840 288840 CAFETERIA REVENUE 900099 236764 236764 551464 551464 2154662 57485871 52677461 32620 4416218 X 142504 142504 1304879 1152353 152526 24530034 21662737 2867297 447341 395052 52289 3501962 3092620 409342 1730277 1528026 202251 465974 411507 54467 208161 183829 24332 6621803 5847785 774018 325536 287484 38052 5878043 5190963 687080 4138647 3654884 483763 64349 56827 7522 1474457 1302109 172348 2915599 2574797 340802 511148 451400 59748 HAF FEE 1085850 998982 86868 DUES & SUB. 170306 150399 19907 210103 150228 59875 55726973 49234486 6492487 0 1480670 2649728 9363132 10931403 393013 489249 866863 908280 602056 565618 80688793 52029079 26094435 28659714 15890722 14338634 1340126 4064801 529380 279218 56560397 62886645 2698794 3518361 20025091 21319590 1111579 3334771 5059145 4867045 28894609 33039767 X 26386889 28876633 1278899 970245 27665788 29846878 56560397 62886645 X 1758898 1224215 -802023 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 1126 1126 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: PAY MEMBERSHIP DUES TO TRADE ORGANIZATIONS OF WHICH A PORTION OF THE DUES ARE USED FOR LOBBY EXPENSES BY THE TRADE ORGANIZATIONS. 1244594 1244594 52811979 32878530 19933449 25037397 19150549 5886848 1594823 1594823 28659714 3028378 F 1036423 C 4064801 LINE OF CREDIT 1051181 DERIVIATIVE LIABILITY 2641669 ESTIMATED THIRD PARTY SETTLEMENTS 1174195 4867045 X 58079842 1224215 -493369 730846 57348996 208161 -71286 136875 57485871 55590098 71286 71286 55518812 208161 208161 55726973 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA REQUIRE MANAGEMENT TO EVALUATE TAX POSITIONS TAKEN BY THE SYSTEM AND RECOGNIZE A TAX LIABILITY IF THE SYSTEM 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 SYSTEM, AND HAS CONCLUDED THAT AS OF SEPTEMBER 30, 2013 AND 2012, 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. AS SUCH, THE SYSTEM IS GENERALLY EXEMPT FROM INCOME TAXES. HOWEVER, THE SYSTEM IS REQUIRED TO FILE FEDERAL FORM 990 - RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX WHICH IS AN INFORMATIONAL RETURN ONLY. THE SYSTEM IS SUBJECT TO ROUTINE AUDITS BY TAXING JURISDICTIONS; HOWEVER, AS OF THE DATE THE FINANCIAL STATEMENTS WERE ISSUED, THERE WERE NOT AUDITS FOR ANY TAX PERIODS IN PROGRESS. PART XI, LINE 2D - OTHER ADJUSTMENTS: LOSS ON DEBT EXTINGUISHMENT -493,369. PART XI, LINE 4B - OTHER ADJUSTMENTS: LOSS ON FIXED ASSETS -13,033. RENT EXPENSES -58,253. PART XII, LINE 2D - OTHER ADJUSTMENTS: LOSS ON FIXED ASSETS 13,033. RENT EXPENSES 58,253. 1 1 1 X 1 X 1 0 1 1 675620 675620 0.01210 10771142 8199824 2571318 0.04610 11446762 8199824 3246938 0.05820 143 56397 56397 0.00100 143 56397 56397 0.00100 143 11503159 8199824 3303335 0.05920 3 78573 78573 0.00140 3 78573 78573 0.00140 0 5797561 0 10391646 13175871 -2784225 X 1 0 1 1 FAYETTE REGIONAL HOSPITAL SYSTEM

1941 VIRGINIA AVE CONNERSVILLE IN 47331

HTTP://WWW.FAYETTEREGIONAL.ORG X X X FAYETTE MEMORIAL HOSPITAL ASSOCIATION 1 1 X X X X X X X X X 12 1 0 1 X X X X 1 0 1 1 150.000000000000 1 200.000000000000 1 X X X X X 0 0 1 0 1 X 0 0 PART I, LINE 3C: THE HOSPITAL HAS A SLIDING SCALE BASED ON THE FEDERAL POVERTY GUIDELINES WITH FREE CARE TO INDIVIDUALS WHO HAVE INCOME BETWEEN 100% AND 133% OF POVERTY AND PROVIDE DISCOUNTED CARE UP TO INCOME OF 300% OF POVERTY. THE LARGEST NUMBER OF THE ORGANIZATION'S PATIENTS MEET THE FEDERAL POVERTY GUIDELINES FOR DISCOUNTED CARE AROUND 200% DEPENDING ON THE HOUSEHOLD SIZE. PART I, LINE 6A: ORGANIZATION'S COMMUNITY BENEFIT REPORT IS AVAILABLE UPON REQUEST. PART II: FRHS EMPLOYEES PARTICIPATE IN COMMUNITY BUILDING ACTIVITIES TO PROMOTE THE HEALTH OF THE COMMUNITIES IT SERVES. PART III, LINE 4: FOOTNOTE TO ORGANIZATION'S FINANCIAL STATEMENTS THAT DESCRIBES BAD DEBT EXPENSES CAN BE FOUND IN THE AUDITED FINANCIAL STATEMENTS ATTACHED ON PAGE 8 UNDER "NEW ACCOUNTING PRONOUNCEMENT", PAGE 9 "PATIENT ACCOUNTS RECEIVABLE AND, NET PATIENT SERVICE REVENUE" AND, PAGE 9 AND 10 "ALLOWANCE FOR DOUBTFUL ACCOUNTS". PART III, LINE 3: RATIONAL FOR INCLUDING OTHER BAD DEBT AMOUNT IN COMMUNITY BENEFIT: NONE HAS BEEN INCLUDED. THE HOSPITAL HAS A DETAILED CHARITY CARE POLICY WHICH STATES THAT TO PARTICIPATE IN CHARITY CARE CANDIDATES MUST COOPERATE FULLY. IN ADDITION THE HOSPITAL EDUCATES PATIENTS WITH 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 SOURCE USED TO DETERMINE THE AMOUNT OF MEDICARE ALLOWABLE COSTS REPORTED FOR PART III, SECTION B, MEDICARE HAS BEEN PROVIDED FROM THE YEAR ENDED SEPTEMBER 30, 2013 REPORT: HOSPITAL STATEMENT OF REIMBURSABLE COST. FAYETTE MEMORIAL HOSPITAL ASSOCIATION PART V, SECTION B, LINE 3: FAYETTE REGIONAL HEALTH SYSTEM HELPED ORGANIZE A STEERING COMMITTEE COMPRISED OF COMMUNITY REPRESENTATIVES INCLUDING BUSINESS OWNERS, LOCAL OFFICIALS, HEALTHCARE PROVIDERS, MINORITY LEADERS, CLERGY, STUDENT REPRESENTATIVES, AND OTHER INTERESTED PARTIES. A 37-QUESTION SURVEY WAS DEVELOPED AND WIDELY DISSEMINATED TO THE RESIDENTS IN THE HOSPITAL'S SERVICE AREA VIA THE HOSPITAL'S WEBSITE, FACE-TO-FACE POLLING AT CONNERSVILLE WAL-MART AND COUNTY FARMERS' MARKET, AND MADE OPENLY AVAILABLE ON SURVEYMONKEY.COM. FAYETTE MEMORIAL HOSPITAL ASSOCIATION PART V, SECTION B, LINE 5C: THE CHNA CAN BE FOUND ON THE HOSPITAL'S WEBSITE: HTTP://WWW.FAYETTEREGIONAL.ORG/CONTACT/SURVEY FAYETTE MEMORIAL HOSPITAL ASSOCIATION PART V, SECTION B, LINE 12H: CHARITY DISCOUNTS CAN BE GRANTED FOR DECEASED PATIENTS WITH NO ESTATE. FAYETTE MEMORIAL HOSPITAL ASSOCIATION PART V, SECTION B, LINE 20D: THE HOSPITAL PROVIDES A DISCOUNT ON CHARGE MASTER RATES BASED ON THE FEDERAL POVERTY GUIDELINES FOR INDIVIDUALS THAT ARE ELIGIBLE FOR FINANCIAL ASSISTANCE. PART VI, LINE 2: THE ORGANIZATION ASSESSES THE HEALTH CARE NEEDS OF THE COMMUNITIES IT SERVES THROUGH ONGOING COMMUNICATION WITH LOCAL COMMUNITY LEADERS AND ORIGINATIONS. THE HOSPITAL TEAM MEMBERS REGULARLY PARTICIPATE IN COMMUNITY EVENTS AND LOCAL CIVIC ORGANIZATIONS INCLUDING ROTARY, KIWANIS, AND CHAMBER OF COMMERCE. COMMUNITY NEEDS ARE DISSEMINATED THROUGH THESE LOCAL COMMUNITY ORGANIZATIONS AND EVENTS PROVIDING THE HOSPITAL WITH FEEDBACK REGARDING THE NEEDS OF THE COMMUNITY. IN ADDITION THE HOSPITAL COMPLETES AND SUBMITS ANNUALLY A COMMUNITY BENEFIT PLAN TO THE INDIANA STATE DEPARTMENT OF HEALTH WHICH ADDRESSES THE GOALS SET TO FOCUS ON THE NEEDS OF THE COMMUNITY.FRHS RECOGNIZES FIVE PRIMARY AREAS OF CONCERN FACING ITS COMMUNITY AS THE FRHS EMPHASIS IN THE IMPLEMENTATION OF THE COMMUNITY BENEFIT PLAN: 1. CITIZENS WHO ARE MEDICALLY UNDERSERVED. 2. ISSUES THAT IMPACT ADOLESCENTS INCLUDING EDUCATION, PREGNANCY AND GENERAL BEHAVIORAL CONCEPTS SPECIFIC TO THIS AGE GROUP. 3. CHILDHOOD GROWTH AND DEVELOPMENT, AS WELL AS ABUSE AND NEGLECT PREVENTION. 4. HEALTH ISSUES THAT REQUIRE INCREASED AWARENESS IN THE GENERAL COMMUNITY POPULATION. 5. CHALLENGES IMPACTING THE AREA WHICH DIRECTLY RELATE TO THE COMMUNITY'S ABILITY TO OBTAIN COMPREHENSIVE MEDICAL CARE. PART VI, LINE 3: ELIGIBILITY FOR ASSISTANCE UNDER FEDERAL, STATE, OR LOCAL GOVERNMENT PROGRAMS OR UNDER THE ORGANIZATION'S CHARITY CARE POLICY IS DISCUSSED WITH PATIENTS OR GUARANTORS TO INFORM AND EDUCATE PATIENTS AND PERSONS WHO MAY BE BILLED FOR PATIENT CARE. CHARITY CARE APPLICATIONS AND PAMPHLETS DETAILING BILLING PROCEDURES AND CONTACT INFORMATION FOR THE BILLING OFFICE ARE MADE AVAILABLE TO PATIENTS. ANY QUESTIONS REGARDING THE ORGANIZATION'S WRITTEN CHARITY CARE POLICY CAN BE DIRECTED AND ANSWERED BY A MEMBER OF THE PATIENT ACCOUNTS' PERSONNEL. PATIENT ACCOUNTS' PERSONNEL WILL NOTIFY INDIVIDUALS WITH APPROVED APPLICATIONS QUALIFYING FOR REDUCED LIABILITY UNDER THE CHARITY CARE POLICY. FRHS STAFFS A FULL TIME REPRESENTATIVE FROM CLAIMAID CONSULTING 5 DAYS A WEEK TO ASSIST COMMUNITY MEMBERS WITH ELIGIBILITY FOR ASSISTANCE FOR PROGRAMS SUCH AS MEDICAID, HIP, AND OTHER PRIVATE ASSISTANCE PROGRAMS. PART VI, LINE 4: FRHS'S MAIN AREAS OF SERVICE ARE FAYETTE, FRANKLIN AND UNION COUNTIES SERVING AN APPROXIMATE POPULATION OF 54,000. FAYETTE COUNTY HAS RANKED IN THE TOP TWO COUNTIES FOR UNEMPLOYMENT IN THE PAST SEVERAL YEARS AND HAS A HIGH NUMBER OF PRIVATE PAY INDIVIDUALS. UNION COUNTY AND FRANKLIN COUNTY HAVE LITTLE TO NO INDUSTRY.PART VI, LINE 5: DURING THE FISCAL YEAR FRHS HAS DEMONSTRATED CONTINUED COMMUNITY STEWARDSHIP THROUGH THE ATTAINMENT OF MANY GOALS THAT ADDRESS THE NEEDS OF OUR COMMUNITY. WE CONTINUE TO STRIVE FOR EXCELLENCE IN THE CONTRIBUTIONS AND SERVICES THAT WE PROVIDE TO AREA CITIZENS. DETAILS FOR FURTHERING FRHS'S EXEMPT PURPOSE FOR **MEDICALLY UNDERSERVED CITIZEN: THE FRANKLIN COUNTY COMMUNITY HAS CONTINUED TO BENEFIT FROM THE SERVICES AT THE BROOKVILLE HEALTHPLEX FACILITY WITH LABORATORY AND RADIOLOGY SERVICES. SUSTAINED CARDIOLOGY AND ONCOLOGY SERVICES WITH THE FRHS CARE CENTERS ENABLE PATIENTS TO BE SEEN LOCALLY FOR MORE ACCESSIBLE CARE WITH LESS TRAVEL, TIME AND EXPENSE. THE ST VINCENT CARDIOLOGY GROUP CONTINUES TO ADDRESS THE NEED FOR LOCAL SERVICES FOR OUR CARDIAC PATIENTS, DECREASING THE COST OF COMMUTING. RADIATION ONCOLOGY WAS ADDED TO OUR CANCER CENTER TO DECREASE COMMUTE DEMANDS ON PATIENTS THAT REQUIRE THIS TREATMENT. AN IMMEDIATE CARE FACILITY HAS REMAINED OPEN IN CONNERSVILLE TO ASSIST PATIENTS TO BETTER ACCESS CARE WITHOUT EXPENSIVE TRAVEL AND TRANSPORTATION ARRANGEMENTS FOR THOSE WITHOUT VEHICLES. THIS SERVICE DECREASES PATIENT COSTS AS IT IS NOT AS EXPENSIVE AS A VISIT TO THE EMERGENCY DEPARTMENT. LABORATORY AND RADIOLOGY SERVICES FURTHER HELP PATIENTS TO REMAIN LOCAL FOR TESTING.SPONSORSHIP OF THE ANNUAL COMMUNITY HEALTH FAIRS IN FAYETTE, UNION AND FRANKLIN COUNTIES WITH EXTENSIVE REPRESENTATION OF FRHS SERVICES BY STAFF HAS CONTINUED. A WIDE ARRAY OF SCREENINGS OFFERED INCLUDED BLOOD PRESSURE, BLOOD SUGAR, CHOLESTEROL AND BONE DENSITY. TEAM MEMBERS WERE AVAILABLE TO HELP PARTICIPANTS UTILIZE HEALTH RISK SURVEYS AS WELL AS TO EDUCATE THEM ON A VARIETY OF HEALTH ISSUES. ALL ATTEMPTS ARE MADE TO OFFER FREE HEALTH AIDES SUCH AS PILL DISPENSERS, NUTRITIONAL GUIDES FOR FAST FOOD RESTAURANTS, ETCETERA. TWO CARDIAC SCORING PROCEDURES, FEMALE WELLNESS EXAM, AND CHOLESTEROL SCREENING CERTIFICATES WERE AMONG THE BOOTH PRIZES GIVEN AWAY AT THE EVENT. THERE WAS AN FRHS PRESENCE IN COMMUNITY HEALTH FAIRS IN 2013 OFFERED BY STAFF INCLUDING TWO IN AN INDUSTRIAL SETTING AT ROOTS BLOWER & SAPA FOR EASY ACCESS FOR THEIR EMPLOYEES. AS IN THE PAST YEAR, STAFF WAS INVOLVED WITH A HEALTH FAIR AT THE FRANKLIN COUNTY LIBRARY THAT ADDRESSED HEALTH NEEDS IN THAT COMMUNITY.MULTIPLE VOLUNTEERS WERE INVOLVED IN FOOD PANTRIES AND MINISTRIES TO ASSIST LOW INCOME INDIVIDUALS WITH NUTRITIONAL AID WHICH IMPACT THEIR GENERAL HEALTH. AN FRHS FOOD DRIVE IS HELD IN FEBRUARY TO ASSIST WITH THE POST-HOLIDAY NEED FOR FOOD. THIS SERVICE CANNOT BE UNDERVALUED AT AN ECONOMIC TIME WHEN MANY FAMILIES HAVE BASIC NUTRITIONAL NEEDS THAT ARE NOT BEING MET IN A MORE TRADITIONAL FASHION. FRHS STAFF HAS HAD A LONG TERM COMMITMENT TO PARTICIPATE IN THE ANGEL FOOD MINISTRIES PROGRAM IN THE SERVICE AREA. FUND RAISING FOR CHARITABLE ORGANIZATIONS INVOLVED IN EDUCATIONAL ASSISTANCE THROUGH SCHOLARSHIP PROGRAMS WAS CONTINUED BY FRHS STAFF. PARTICIPATION IN THE FAYETTE AND FRANKLIN COUNTY RELAY FOR LIFE CANCER SOCIETY EVENTS RAISED FUNDS TO ENABLE CARE/SERVICES FOR ONCOLOGY PATIENTS AND SURVIVORS OF CANCER. ADDITIONALLY, FRHS ASSISTED FURTHER THROUGH ANNOUNCEMENTS FOR THE RELAY AND A MONETARY GIFT. MANY FRHS TEAM MEMBERS AND LEADERSHIP STAFF CONTRIBUTED TIME TO WALK DURING THE 24 HOUR EVENT. THERE WAS ALSO PARTICIPATION IN THE STATE SUSAN B KOMEN WALK IN INDIANAPOLIS. AN FRHS TEAM MEMBER IS ON THE CANCER SOCIETY BOARD AND ATTENDS MONTHLY MEETINGS. FINANCIAL DONATIONS WERE PROVIDED FOR ACTIVITIES INCLUDING THE DONUT DAYS AND JEANS DAYS TO RAISE FUNDS. A BREAST CANCER AWARENESS TABLE WAS AVAILABLE IN THE FRHS ATRIUM TO EDUCATE PATIENTS AND STAFF. FRANKLIN AND FAYETTE COUNTY CANCER SOCIETIES BOTH RECEIVED A DONATION FROM FRHS. BREAST CANCER AWARENESS IN PARTICULAR WAS SUPPORTED IN 2012 WITH THE PINK PJ PARTY FOR BREAST CANCER AWARENESS THAT INCLUDED A FASHION SHOW. SEVERAL COMMUNITY SERVICE GROUPS INCLUDING PSI IOTA XI, TRI KAPPA, AND ETA PI KAPPA WERE ASSISTED WITH PROGRAMS AND PROJECTS THAT DIRECTLY IMPROVED THE MEDICAL OUTCOME FOR COMMUNITY MEMBERS WHILE ALSO INCREASING HEALTH EDUCATION. MANY HOURS WERE DONATED BY FRHS STAFF TO THE LOCAL HOPE PREGNANCY CRISES CENTER AS WELL AS THE HOUSE OF RUTH SHELTER FOR PROGRAMS AND PROJECTS TO HELP MEET THE NEEDS OF THIS POPULATION. THERE WAS A SILENT AUCTION THIS YEAR THAT STAFF SUPPORTED. A LOCAL GOLF TOURNEY AND THE ANNUAL GALA EVENT HAVE RAISED FUNDS TO PROVIDE ADDITIONAL HEALTH SERVICES TO THE COMMUNITY AS WELL AS TO UPDATE FACILITIES. AREA 9 AGENCY ON AGING WAS SUPPORTED MONETARILY FOR THE ANNUAL PICNIC AS WELL AS THE VOLUNTEER LUNCH FOR THE PLANNING PROCESS. **ADOLESCENT POPULATION ISSUES: THE WHITEWATER CARE PAVILION OFFERS COMPREHENSIVE BEHAVIORAL HEALTH SERVICES FOR ADOLESCENTS INCLUDING RESIDENTIAL, ACUTE INPATIENT CARE AND OUTPATIENT THERAPY OPTIONS. FRHS ENCOURAGED YOUTH TO BE ACTIVE AND HEALTH CONSCIOUS THROUGH COACHING AND SEVERAL SPONSORSHIPS FOR YOUTH SPORTS GROUPS INCLUDING BASKETBALL, GYMNASTICS, WRESTLING, FRANKLIN COUNTY BOYS BASEBALL, CONNERSVILLE PARKS AND RECREATION PROGRAM, CAST SWIMMING, CHEERLEADING AND A 5K RUN. A STAFF MEMBER DONATED OVER 300 HOURS AS A FOOTBALL COACH AT LINCOLN HIGH SCHOOL. CONNERSVILLE AND THE BROOKVILLE COMMUNITIES WERE ASSISTED BY TWO ATHLETIC TRAINERS THROUGH FRHS FINANCIAL PARTICIPATION THAT EQUALED OVER 4,000 HOURS. 180 HOURS WERE DONATED FOR A FRIDAY NIGHT YOUTH PROGRAM AT THE CROSSPOINT BIKER CHURCH. A TEAM MEMBER WAS A GUEST SPEAKER AT THE CAREER CENTER, CONNERSVILLE HIGH SCHOOL, FOR CAREER/ VOCATIONAL DAY AND AT BALL STATE. MANY LOCAL YOUTH GROUPS AND INDIVIDUAL CHILDREN WERE ASSISTED BY FRHS STAFF THROUGH ACTIVITIES SUCH AS 4H FAIR, BOYS AND GIRLS CLUB, AND BIG BROTHERS/BIG SISTERS. BOY SCOUTS AND GIRL SCOUTS WERE ALSO SUPPORTED. SEVERAL SPORTS PHYSICALS FOR LOCAL HIGH SCHOOL AND ELEMENTARY YOUTH WERE SPONSORED AND STAFFED BY FRHS TEAM MEMBERS, ENABLING THEM TO PARTICIPATE IN SCHOOL SPORTS PROGRAMS AND WERE COMPLETED BY FRHS PHYSICIANS. AS WELL, TEAM MEMBER PROVIDED BLOOD PRESSURE CHECKS AT COMMUNITY BASKETBALL GAMES. PROM AND AFTER PROM WERE SPONSORED BY FRHS DONATIONS. ST GABRIEL'S AMERICAN HERITAGE GIRLS (WHICH IS SIMILAR TO GIRL SCOUTS) WAS SUPPORTED BY A STAFF MEMBER BY VOLUNTEERING AS A GROUP LEADER. ADDITIONALLY, OVER 50 HOURS WERE DONATED TO SUPPORT OTHER SCHOOL AND CHURCH EVENTS AT ST GABRIEL'S SCHOOL. JUNIOR ACHIEVEMENT BANQUET WAS SUPPORTED BY FRHS. FRHS PURCHASED THE SCORE BOARD FOR THE BABE RUTH LEAGUE BALLPARK FOR LOCAL BASEBALL LEAGUES FOR AREA YOUTH. STAFF MEMBER DONATED TIME ON THE ADVISORY BOARD FOR THE WHITE WATER TECH CAREER CENTER AND VOLUNTEERED AT THE LINK FUNDRAISER. OVER 100 HOURS WERE ALSO DONATED BY FRHS STAFF FOR AN AFTER SCHOOL PROGRAM THROUGH THE LINK PROGRAM. HEALTH CARE PROFESSIONALS SPOKE AT LOCAL CLASSES, AND PARTICIPATED IN FUNDRAISING FOR SCHOLARSHIPS. FOOD, CLOTHING, AND SHELTER PROVISIONS ARE PROVIDED IN COOPERATION WITH COMMUNITY CHURCHES, MISSIONS, SORORITY ACTIVITIES, AND SCHOOL CORPORATION PROJECTS. FRHS STAFF DONATED TIME TO THE LOCAL HOPE PREGNANCY CARE CENTER FOR PROGRAMS AND PROJECTS TO HELP MEET THE NEEDS OF THIS POPULATION. A BABY FORMULA PROGRAM THROUGH THE HOPE PREGNANCY CENTER IS AVAILABLE FOR TEEN MOTHERS FOR THEIR BABY'S NUTRITIONAL NEEDS. DONATIONS WERE OFFERED TO THE CONNERSVILLE HIGH SCHOOL ATHLETICS AND BAND PROGRAMS INCLUDING THE CROSS COUNTRY TEAM. PART VI, LINE 5: **CONTINUE OF ADOLESCENT POPULATION** 48 HOURS WERE DONATED BY A STAFF MEMBER FOR THE JUNIOR SHOOTING SPORTS WITH THE AMERICAN LEGION. THIS STAFF MEMBER IS ALSO FINANCE OFFICER FOR THE 10TH DISTRICT IN INDIANA. ANOTHER STAFF MEMBER TEACHES GUN SAFETY AT A LOCAL FIRING RANGE. FRHS STAFF ASSISTED WITH TICKET SALES FOR THE FRANKLIN COUNTY SPRING PLAY. THERE CONTINUED TO BE STRONG PARTICIPATION IN THE FAYETTE CO. 4H FAIR BY PURCHASING LIVESTOCK FROM TEAM MEMBERS CHILDREN THAT PARTICIPATE IN THESE PROGRAMS AS WELL AS SPONSORSHIP IN FRANKLIN COUNTY 4H FAIR ACTIVITIES.**CHILDHOOD ISSUES: CHRISTMAS GIVING TO THE DIVISION OF FAMILY AND CHILDREN INITIATIVE WHERE DEPARTMENTS SPONSOR NEEDY CHILDREN AT THE HOLIDAY WITH SHOES, CLOTHING, BOOKS AND TOYS WAS AGAIN SUPPORTED BY FRHS DEPARTMENT STAFF. THE DEPARTMENTS SUPPORT CHILDREN ACTIVITIES SUCH AS CHURCH HOLIDAY PROGRAMS, THE 4H FAIR, GIRL SCOUTS, BOY SCOUTS AND CUB SCOUTS. FRHS STAFF MEMBER HANDED OUT BACKPACKS WITH SCHOOL SUPPLIES AT THE PARK ROAD CHRISTIAN CENTER. 88 HOURS WERE DONATED TO THE SAMARITAN'S PURSE OPERATION CHRISTMAS CHILD THROUGH WORK AS A CHURCH AND COMMUNITY RELATIONS VOLUNTEER AS WELL AS PACKING BOXES. EVERTON ELEMENTARY SCHOOL OFFERED SEVERAL VOLUNTEER OPPORTUNITIES FOR STAFF TO HELP READ WITH STUDENTS AND OTHER SCHOOL EVENTS. TEAM MEMBERS VOLUNTEERED HOURS FOR A VARIETY OF DIVISION FOR FAMILY AND CHILDREN ACTIVITIES INCLUDING A GIFT DRIVE AT CHRISTMAS, A COAT DRIVE, A BOOK DRIVE AND A FOOD DRIVE TO BENEFIT FAMILIES IN OUR AREA. ENJOYMENT COMBINED WITH CHARITY IN THE COMMUNITY PROGRAMS THAT INCLUDE THE BIKE RODEO SAFETY EVENT AND THE THOMAS THE TRAIN ACTIVITY WHICH BENEFITED THE HOUSE OF RUTH SHELTER LOCALLY. A DONATION TO THE UNITED YOUTH PROJECT WAS OFFERED. **INCREASING HEALTHCARE-RELATED ISSUES AWARENESS AND EDUCATION: SPEAKING ENGAGEMENTS WERE DONATED BY STAFF ON A VARIETY OF HEALTH ISSUES AT LOCAL SCHOOL, EVENTS AND COMMUNITY GROUPS. FRHS HAS COORDINATED LIVING THROUGH GRIEF AND LIVING THROUGH CANCER GROUPS FOR TEN YEARS TO COUNSEL AND SUPPORT FAMILIES THROUGH DIFFICULT FAMILY SITUATIONS. SMOKING CESSATION PROGRAM IS AVAILABLE THROUGH THE FRHS HEALTH WORKS DEPARTMENT. FRHS HOME HEALTH OFFERS BLOOD PRESSURE AND BLOOD GLUCOSE CLINICS AT VARIOUS SITES IN FRANKLIN, FAYETTE AND UNION COUNTY. A TEAM MEMBER IS ON THE LOCAL PROLIFE COMMITTEE AND STAFF HAVE PARTICIPATED IN THE LIFE CHAIN EVENT IN THE COMMUNITY. NUTRITIONAL PROGRAMS AT THE FAYETTE COUNTY COURTHOUSE, IVY TECH, AND SEVERAL OTHER COMMUNITY CENTERS WERE PRESENTED IN THE PAST YEAR. ALSO, STAFF PREPARED A PROGRAM FOR THE DIABETES SUPPORT GROUP. 60 CASES OF WATER WERE DONATED TO THE COMMUNITY FOOD BANK FROM THE FRHS DIETARY DEPT. A STAFF MEMBER DONATED OVER 100 HOURS WORKING AT THE LORD'S KITCHEN BY SHOPPING, COOKING, SERVING AND CLEANING UP AT THIS LOCAL SOUP KITCHEN FOR THE NEEDY. ANOTHER STAFF MEMBER DONATED OVER 200 HOURS WITH THE COMMUNITY SHARING PROGRAM HANDING OUT FOOD AT THE FAYETTE COUNTY ANNEX BUILDING. CPR AND FIRST AID ARE TAUGHT BY AN FRHS VOLUNTEER AT NURSING HOMES AND A LOCAL BUSINESS. TEAM MEMBER WAS THE OUTPATIENT CLINICAL INSTRUCTOR FOR THE DPT STUDENTS. FRHS STAFF HAVE PARTICIPATED AND CONTRIBUTED TO THE WALK FOR ALZHEIMER'S, WALK FOR AUTISM, WALK A MILE IN HER SHOES (DOMESTIC VIOLENCE AWARENESS) AND THE HOME RUN 5K RUN FOR THE HIGH SCHOOL.**OTHER AREAS OF PARTICIPATION BEYOND THE PREVIOUSLY STATED GOALS INCLUDE: THE FRHS FOUNDATION IS A CAUSE THAT FRHS STAFF SUPPORTS ANNUALLY THROUGH A VARIETY OF FUNCTIONS SUCH AS THE GOLF OUTING. OVER 80 HOURS WERE DONATED BY STAFF. ALSO, TEAM MEMBERS VOLUNTEERED 143 HOURS FOR PREPARATION FOR THE FOUNDATION BOOTS AND BLING FUNDRAISER. OVER 1000 HOURS WERE DONATED BY FRHS THROUGH PARTICIPATION IN LOCAL MINISTRIES INCLUDING VBS, CHURCH ACTIVITIES, FOOD DRIVES AND PANTRIES, AND CHRISTMAS PROGRAMS FOR THE NEEDY INDIVIDUALS IN OUR COMMUNITIES. TWIN CITY MISSION IS A PROGRAM THAT ASSISTS WITH REPAIRING HOMES. A TEAM MEMBER DONATED 65 HOURS FOR THIS MISSION. MANY STAFF MEMBERS VOLUNTEERED TIME AND SERVICES FOR A LOCAL FUNDRAISER FOR THE SON OF A TEAM MEMBER, TO ASSIST HIS FAMILY WITH EXPENSES DURING HIS ILLNESS TEAM MEMBER IS THE CHAPLAIN AND TREASURER FOR THE LADIES AUXILIARY AT THE EAGLES CLUB, VOLUNTEERING FOR MEETINGS, ORGANIZING EVENTS AND PARTICIPATING IN COMMUNITY EVENTS WITH THE EAGLES. OVER $14,000 WAS DONATED FOR MINISTERIAL SERVICES FOR FRHS PATIENTS AND FAMILIES. FRHS DONATED SERVICES AND TESTING FOR FUNDRAISERS AT VARIOUS COMMUNITY CHARITY EVENTS. CONTRIBUTED FINANCIALLY TO THE CONNERSVILLE AND FRANKLIN COUNTY CHAMBER OF COMMERCE, KIWANIS, JAYCEES, OPTIMIST CLUB, CONNERSVILLE FOP, BICENTENNIAL COMMITTEE, AND VONDA BISHOP MINISTRIES CHARITY. DONATION TO THE CAMBRIDGE CITY FIRE DEPT FOR THE WESTERN WAYNE FIREMAN 5K RUN. ADDITIONALLY, A STAFF MEMBER CONTRIBUTED 174 HOURS AS A VOLUNTEER FIREMAN IN EVERTON. BLOOD WAS DONATED BY STAFF MEMBERS FOR THE BLOOD DRIVE SPONSORED BY FRHS. CONNERSVILLE IS CELEBRATING ITS BICENTENNIAL IN 2013. A STAFF MEMBER IS ON THAT COMMITTEE TO PLAN THIS EVENT. A FINANCIAL DONATION IS ALSO INCLUDED IN THE FRHS SUPPORT OF THIS UPCOMING COMMUNITY CELEBRATION. WE CONTINUE TO SEARCH FOR NEW AVENUES TO INCREASE THE AWARENESS AND HEALTH STATUS OF THE CITIZENS OF OUR MULTI COUNTY AREA. PART VI, LINE 6: NOT APPLICABLE. ORGANIZATION IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM. REPORTS FILED WITH STATES PART VI, LINE 7 IN 0 FAYETTE COUNTY SCHOOLS 1941 VIRGINIA AVE CONNERSVILLE IN 47331 N/A 9000 COST OF SERVICES ATHLETIC TRAINER SERVICES DONATED ATHLETIC TRAINER SERVICES CONNERSVILLE BICENTENNIAL 1941 VIRGINIA AVE CONNERSVILLE IN 47331 N/A 5000 CONTRIBUTIONS TO PROVIDE THE BICENTENNIAL CELEBRATION FAYETTE COUNTY MINISTERIAL ASSOCIATION 1941 VIRGINIA AVE CONNERSVILLE IN 47331 N/A 14300 CONTRIBUTIONS TO PAY SALARY & BENEFITS FOR REVEREND. CONNERSVILLE HIGH SCHOOL AND 1941 VIRGINIA AVE CONNERSVILLE IN 47331 N/A 63523 CONTRIBUTIONS TO PAY SALARY AND BENEFITS FOR ATHLETIC TRAINERS FOR COMMUNITY HIGH SCHOOLS 0 4 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: ASSISTANCE IS PROVIDED TO PUBLIC CHARITIES FOR GENERAL SUPPORT. THE ORGANIZATION DOES NOT MONITOR THE USE OF THESE FUNDS BY THESE PUBLIC CHARITIES. IN ADDITION THE ORGANIZATION MAKES SCHOLARSHIPS AND STUDENT LOANS AVAILABLE TO ELIGIBLE PERSONS TO FURTHER HEALTHCARE IN THE COMMUNITY. 1 X X X X 0 0 0 0 0 0 0 1 0 DR PETRONIO ILAGAN 272079 0 0 0 12000 0 7500 0 6784 0 298363 0 0 0 MICHAEL ROWE MD 421841 0 0 0 0 0 7500 0 6461 0 435802 0 0 0 JAG PATEL MD 292548 0 0 0 6000 0 7500 0 4788 0 310836 0 0 0 RANDALL WHITE 273052 0 0 0 0 0 7500 0 11707 0 292259 0 0 0 GARY SMITH 152885 0 0 0 0 0 4785 0 6601 0 164271 0 0 0 BETH WAMPLER 168306 0 0 0 0 0 5369 0 10667 0 184342 0 0 0 STEPHEN CASTLEMAN MD 390405 0 0 0 0 0 7500 0 6746 0 404651 0 0 0 JOHN LANDRY MD 293105 0 0 0 0 0 7500 0 7215 0 307820 0 0 0 STEVEN JOHNSON MD 291495 0 0 0 0 0 7500 0 8803 0 307798 0 0 0 HATEM DAJANI MD 287872 0 0 0 0 0 7500 0 300 0 295672 0 0 0 CAROL HULETT MD 285523 0 0 0 0 0 1962 0 539 0 288024 0 0 0 PART I, LINE 7 PERFORMANCE INCENTIVE PAY IS A GOAL-BASED NON-FIXED PAYMENT THAT IS DIRECTLY TIED TO THE PERFORMANCE OF THE INDIVIDUAL IN ACHIEVING PERSONAL AND ORGANIZATIONAL GOALS. THE PROGRAM IS GOVERNED BY THE BOARD OF TRUSTEES AND DELEGATED TO THE EXECUTIVE COMMITTEE OF THE BOARD TO BE REVIEWED AND APPROVED. PAYOUTS ARE BASED ON EACH INDIVIDUAL'S PERFORMANCE AGAINST PRE-DEFINED GOALS AND OBJECTIVES ALIGNED WITH THE OVERALL MISSION, VISION, AND STRATEGIC GOALS OF THE ORGANIZATION AND THE PROFITABILITY OF FRHS FOR THE FISCAL YEAR. IF THE HOSPITAL MEETS OR EXCEEDS BUDGET WITH RESPECT TO EXCESS REVENUE OVER EXPENSES EXCLUDING ANY INTEREST INCOME, EACH EMPLOYEE WILL RECEIVE ON WEEK'S PAY BASED UPON AN AVERAGE NUMBER OF REGULAR SCHEDULED HOURS WORKED PER WEEK. A INDIANA FINANCE AUTHORITY 351602316 2013-08-21 21106000 SEE PART VI 0 0 0 A 21106000 280448 1999861 18825691 1 0 0 1 A 0 0 1 1 0 0.00000 0.00000 0.00000 0 0 0 A 0 1 0 0 1 0 0 0 1 A 1 SCH K, PART I, LINE A, COLUMN (F), DESCRIPTION OF PURPOSE: THE PROCEEDS OF THE INDIANA FINANCE AUTHORITY HEALTH FACILITY REVENUE AND REFUNDING BONDS, SERIES 2013, ARE BEING USED TO COVER THE COST OF ISSUING THE BONDS; REFUND ALL OF THE OUTSTANDING INDIANA HEALTH FACILITY FINANCING AUTHORITY VARIABLE RATE DEMAND REVENUE BONDS, SERIES 2002A AND 2002B ISSUED 2/28/2002 AND 7/3/2002, RESPECTIVELY; AND FINANCE ASSETS FOR CONSTRUCTION OF A NEW 12-BED GERIATRIC/PSYCHOLOGY UNIT IN CONNERSVILLE, INDIANA. DR JAG PATEL BOARD MEMBER AND EMPLOYEE 30000 DR. PATEL OWNS A BUILDING WHICH HE RENTS TO THE HOSPITAL FOR PHYSICIAN OFFICES. 0 FORM 990, PART VI, SECTION B, LINE 11 THE PROCESS OF REVIEWING THE FORM 990 ENTAILS A DETAILED REVIEW OF THE FORM 990 BY THE ORGANIZATION'S CFO AND CONTROLLER. THE GOVERNING BODY REVIEWS AND APPROVES THE FORM 990 INCLUDING REQUESTED SCHEDULES, AS ULTIMATELY FILED WITH THE IRS, AND ARE PROVIDED TO EACH VOTING MEMBER OF THE ORGANIZATION'S GOVERNING BODY PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C ANNUAL INFORMATION ABOUT THE CONFLICT OF INTEREST AND DISCLOSURE ARE PROVIDED TO MEMBERS OF THE BOARD OF TRUSTEES, CHIEF EXECUTIVE OFFICER, ADMINISTRATIVE STAFF, ALL DEPARTMENT MANAGERS, INDIVIDUALS WITH INFLUENCE OVER PURCHASING, AND INDIVIDUALS WITH CONTRACTS TO FAYETTE REGIONAL HOSPITAL SYSTEM. ANNUAL QUESTIONNAIRES ARE TO BE COMPLETED BY EACH MEMBER OF THE BOARD OF TRUSTEES AND THE EXECUTIVE TEAM, THEN REVIEWED AND NOTED IN THE BOARD MINUTES. IN ADDITION, ANY INDIVIDUAL ASSOCIATED WITH FAYETTE REGIONAL HEALTH SYSTEM IS TO DECLARE SITUATIONS OF ACTUAL OR POTENTIAL CONFLICTS OF INTEREST AS THEY ARISE, IN WRITING, AND IN SUFFICIENT DETAIL. FORM 990, PART VI, SECTION B, LINE 15 THE PROCESS FOR DETERMINING COMPENSATION FOR THE CEO IS GOVERNED BY THE BOARD OF TRUSTEES AND DELEGATED TO THE EXECUTIVE COMMITTEE OF THE BOARD TO REVIEW AND APPROVE ANNUALLY. IN ADDITION, ALL EMPLOYMENT CONTRACTS AND AMENDMENTS FOR THE CEO WILL BE REVIEWED AND APPROVED BY THE EXECUTIVE COMMITTEE OF THE BOARD AND CO-SIGNED BY THE CHAIR OF THE BOARD OF TRUSTEES AND THE SECRETARY OF THE BOARD. THE PROCESS FOR DETERMINING COMPENSATION FOR OTHER OFFICERS/KEY EMPLOYEES IS REVIEWED ANNUALLY BY THE EXECUTIVE COMMITTEE AND CEO. THE SECRETARY OF THE BOARD OF TRUSTEES IS RESPONSIBLE FOR RECORDING IN THE MINUTES THE DELIBERATION AND DECISIONS. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, OR FINANCIAL STATEMENTS AVAILABLE UPON REQUEST. OTHER FEES FORM 990, PART IX, LINE 11G PURCHASED SERVICES : PROGRAM SERVICE EXPENSES 5,847,785. MANAGEMENT AND GENERAL EXPENSES 774,018. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 6,621,803. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: CHANGE IN TEMPORARILY RESTRICTED NET ASSETS -308,654. LOSS ON DEBT EXTINGUISHMENT -493,369. OVERSIGHT OF THE AUDIT PART XI, LINE 2C THE AUDIT COMMITTEE ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF THE FINANCIAL STATEMENTS AND SELECTION OF THE INDEPENDENT ACCOUNTANT; AND NO PROCESSES HAVE CHANGED FROM PRIOR YEAR. FAYETTE MEMORIAL HOSPITAL FOUNDATION 1941 VIRGINIA AVENUE CONNERSVILLE IN 47331 311010071 TO BENEFIT FAYETTE REGIONAL HOSPITAL SYSTEM IN 501(C)(3) LINE 11A, I FAYETTE REGIONAL HOSPITAL 1 0 0 1 0 0 0 0 0 0 0 0 1 0 1 1 0 1 0 0 FAYETTE MEMORIAL HOSPITAL FOUNDATION C 359572 FAIR MARKET VALUE FAYETTE MEMORIAL HOSPITAL FOUNDATION L 141480 COST OF SERVICES