Bellville Medical Center: Form 990, tax year 2012
View the entire original 990 at ProPublica ↗
- Organization
- Bellville Medical Center (EIN 27-4005511)
- Tax period
- 2012-01-01 to 2012-12-31
- Filed
- 2013-11-14
- IRS object ID
- 201313189349306201
- Schema version
- 2012v2.1
- Source
- Download XML · Original 990 at ProPublica
Every field in the e-filed return. Faint text is the IRS element name, for citing.
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Timestamp | 2013-11-14T15:49:14-06:00 | Timestamp |
| Tax Period End Date | 2012-12-31 | TaxPeriodEndDate |
Preparer Firm PreparerFirm
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 752570395 | EIN |
Preparer Firm Business Name PreparerFirmBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | DURBIN & COMPANY LLP | BusinessNameLine1 |
Preparer Firm US Address PreparerFirmUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 2950 50TH STREET | AddressLine1 |
| City | LUBBOCK | City |
| State | TX | State |
| ZIP Code | 79413 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnType |
| Tax Period Begin Date | 2012-01-01 | TaxPeriodBeginDate |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 274005511 | EIN |
Name Name
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | BELLVILLE GENERAL HOSPITAL | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Control | BELL | NameControl |
| Phone | 9794137400 | Phone |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 44 NORTH CUMMINGS | AddressLine1 |
| City | BELLVILLE | City |
| State | TX | State |
| ZIP Code | 77418 | ZIPCode |
Officer Officer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | JEFFERY BARNHART | Name |
| Title | ADMINISTRATOR | Title |
| Phone | 9794137400 | Phone |
| Date Signed | 2013-11-14 | DateSigned |
| Authorize Third Party | 1 | AuthorizeThirdParty |
Preparer Preparer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | JONATHAN PHILLIPS | Name |
| PTIN | P01605460 | PTIN |
| Phone | 8067911591 | Phone |
| Date Prepared | 2013-11-14 | DatePrepared |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax Year | 2012 | TaxYear |
| Build TS | 2016-02-25 16:41:14Z | BuildTS |
Form 990 IRS990
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Of Principal Officer Person | JEFFERY BARNHART | NameOfPrincipalOfficerPerson |
Address Principal Officer US AddressPrincipalOfficerUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 44 NORTH CUMMINGS | AddressLine1 |
| City | BELLVILLE | City |
| State | TX | State |
| ZIP Code | 77418 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | 10470814 | GrossReceipts |
| Group Return For Affiliates | 0 | GroupReturnForAffiliates |
| Organization501c3 | X | Organization501c3 |
| Web Site | WWW.BELLVILLEHOSPITAL.COM | WebSite |
| Type Of Organization Corporation | X | TypeOfOrganizationCorporation |
| Year Formation | 2010 | YearFormation |
| State Legal Domicile | TX | StateLegalDomicile |
| Activity Or Mission Description | THE HOSPITAL IS ORGANIZED FOR THE EXCLUSIVE PURPOSES OF OPERATING A COMMUNITY HOSPITAL AND PROVIDING NON-ELECTIVE HEALTHCARE TO THE GENERAL PUBLIC REGARDLESS OF THE ABILITY OF PATIENTS TO PAY FOR THESE SERVICES. | ActivityOrMissionDescription |
| Nbr Voting Members Governing Body | 5 | NbrVotingMembersGoverningBody |
| Nbr Independent Voting Members | 5 | NbrIndependentVotingMembers |
| Total Nbr Employees | 109 | TotalNbrEmployees |
| Total Nbr Volunteers | 0 | TotalNbrVolunteers |
| Total Gross UBI | 0 | TotalGrossUBI |
| Net Unrelated Business Txbl Income | 0 | NetUnrelatedBusinessTxblIncome |
| Contributions Grants Prior Year | 78637 | ContributionsGrantsPriorYear |
| Contributions Grants Current Year | 243105 | ContributionsGrantsCurrentYear |
| Program Service Revenue Prior Year | 11922333 | ProgramServiceRevenuePriorYear |
| Program Service Revenue CY | 9660979 | ProgramServiceRevenueCY |
| Investment Income Prior Year | 1609 | InvestmentIncomePriorYear |
| Investment Income Current Year | 1465 | InvestmentIncomeCurrentYear |
| Other Revenue Prior Year | 289975 | OtherRevenuePriorYear |
| Other Revenue Current Year | 388305 | OtherRevenueCurrentYear |
| Total Revenue Prior Year | 12292554 | TotalRevenuePriorYear |
| Total Revenue Current Year | 10293854 | TotalRevenueCurrentYear |
| Grants And Similar Amnts Prior Year | 0 | GrantsAndSimilarAmntsPriorYear |
| Grants And Similar Amnts CY | 0 | GrantsAndSimilarAmntsCY |
| Benefits Paid To Members Prior Year | 0 | BenefitsPaidToMembersPriorYear |
| Benefits Paid To Members CY | 0 | BenefitsPaidToMembersCY |
| Salaries Etc Prior Year | 4581954 | SalariesEtcPriorYear |
| Salaries Etc Current Year | 5029701 | SalariesEtcCurrentYear |
| Total Prof Fundrsng Exp Prior Year | 0 | TotalProfFundrsngExpPriorYear |
| Total Prof Fundrsng Exp CY | 0 | TotalProfFundrsngExpCY |
| Total Fundrsng Exp Current Year | 0 | TotalFundrsngExpCurrentYear |
| Other Expense Prior Year | 6658378 | OtherExpensePriorYear |
| Other Expenses Current Year | 6782814 | OtherExpensesCurrentYear |
| Total Expenses Prior Year | 11240332 | TotalExpensesPriorYear |
| Total Expenses Current Year | 11812515 | TotalExpensesCurrentYear |
| Revenues Less Expenses Prior Year | 1052222 | RevenuesLessExpensesPriorYear |
| Revenues Less Expenses CY | -1518661 | RevenuesLessExpensesCY |
| Total Assets BOY | 2251510 | TotalAssetsBOY |
| Total Assets EOY | 3663998 | TotalAssetsEOY |
| Total Liabilities BOY | 1199288 | TotalLiabilitiesBOY |
| Total Liabilities EOY | 4130437 | TotalLiabilitiesEOY |
| Net Assets Or Fund Balances BOY | 1052222 | NetAssetsOrFundBalancesBOY |
| Net Assets Or Fund Balances EOY | -466439 | NetAssetsOrFundBalancesEOY |
| Mission Description | THE PRIMARY PURPOSE OF THE HOSPITAL IS TO SUPPORT ITS COMMUNITY IN PROVIDING FOR THE HEALTHCARE NEEDS OF ITS COMMUNITY. | MissionDescription |
| Significant New Program Services | 0 | SignificantNewProgramServices |
| Significant Change | 0 | SignificantChange |
| Expense | 10295126 | Expense |
| Revenue | 10049284 | Revenue |
| Description | HOSPITAL SERVICES THAT INCLUDE BUT ARE NOT LIMITED TO: 1,689 TOTAL PATIENT DAYS, 4,733 EMERGENCY ROOM VISITS, 48,639 LABORATORY PROCEDURES AND 7,559 RADIOLOGY PROCEDURES. THE HOSPITAL ALSO PROVIDED $334,813 IN CHARITY CARE. | Description |
| Total Program Service Expense | 10295126 | TotalProgramServiceExpense |
| Described In501 C3 | 1 | DescribedIn501C3 |
| Schedule B Required | 1 | ScheduleBRequired |
| Political Activities | 0 | PoliticalActivities |
| Lobbying Activities | 0 | LobbyingActivities |
| Subject To Proxy Tax | 0 | SubjectToProxyTax |
| Donor Advised Funds | 0 | DonorAdvisedFunds |
| Conservation Easements | 0 | ConservationEasements |
| Collections Of Art | 0 | CollectionsOfArt |
| Credit Counseling | 0 | CreditCounseling |
| Term Or Permanent Endowments | 0 | TermOrPermanentEndowments |
| Report Land Bldg Equip | 1 | ReportLandBldgEquip |
| Report Invest Oth Securities | 0 | ReportInvestOthSecurities |
| Report Prog Rel Invest | 0 | ReportProgRelInvest |
| Report Other Assets | 1 | ReportOtherAssets |
| Report Other Liabilities | 0 | ReportOtherLiabilities |
| Report Fin48 Footnote | 1 | ReportFin48Footnote |
| Independent Audit Financial Stmt | 1 | IndependentAuditFinancialStmt |
| Consolidated Audit Financial Stmt | 0 | ConsolidatedAuditFinancialStmt |
| School | 0 | School |
| Foreign Office | 0 | ForeignOffice |
| Foreign Activities | 0 | ForeignActivities |
| More Than5000 K To Organizations | 0 | MoreThan5000KToOrganizations |
| More Than5000 K To Individuals | 0 | MoreThan5000KToIndividuals |
| Professional Fundraising | 0 | ProfessionalFundraising |
| Fundraising Activities | 0 | FundraisingActivities |
| Gaming | 0 | Gaming |
| Hospital | 1 | Hospital |
| Financial Stmt Attached | 1 | FinancialStmtAttached |
| Grants To Organizations | 0 | GrantsToOrganizations |
| Grants To Individuals | 0 | GrantsToIndividuals |
| Schedule J Required | 1 | ScheduleJRequired |
| Tax Exempt Bonds | 0 | TaxExemptBonds |
| Excess Benefit Transaction | 0 | ExcessBenefitTransaction |
| Prior Excess Benefit Transaction | 0 | PriorExcessBenefitTransaction |
| Loan To Officer Or DQP | 0 | LoanToOfficerOrDQP |
| Grant To Related Person | 0 | GrantToRelatedPerson |
| Bsnss Rltnshp With Organization | 0 | BsnssRltnshpWithOrganization |
| Bsnss Rltnshp Thru Family Member | 0 | BsnssRltnshpThruFamilyMember |
| Officer Entity With Bsnss Rltnshp | 0 | OfficerEntityWithBsnssRltnshp |
| Deductible Non Cash Contributions | 0 | DeductibleNonCashContributions |
| Deductible Contributions Of Art | 0 | DeductibleContributionsOfArt |
| Terminated | 0 | Terminated |
| Partial Liquidation | 0 | PartialLiquidation |
| Disregarded Entity | 0 | DisregardedEntity |
| Related Entity | 0 | RelatedEntity |
| Related Org Controlled Entity | 0 | RelatedOrgControlledEntity |
| Transfers To Exempt Non Chrtbl Org | 0 | TransfersToExemptNonChrtblOrg |
| Activities Conducted Partnership | 0 | ActivitiesConductedPartnership |
| Schedule O Required | 1 | ScheduleORequired |
| Number Forms Transmitted With1096 | 42 | NumberFormsTransmittedWith1096 |
| Number W2 G Included | 0 | NumberW2GIncluded |
| Compliance With Backup Witholding | 1 | ComplianceWithBackupWitholding |
| Number Of Employees | 109 | NumberOfEmployees |
| Employment Tax Returns Filed | 1 | EmploymentTaxReturnsFiled |
| Unrelated Business Income | 0 | UnrelatedBusinessIncome |
| Foreign Financial Account | 0 | ForeignFinancialAccount |
| Prohibited Tax Shelter Trans | 0 | ProhibitedTaxShelterTrans |
| Taxable Party Notification | 0 | TaxablePartyNotification |
| Non Deductible Contributions | 0 | NonDeductibleContributions |
| Quid Pro Quo Contributions | 0 | QuidProQuoContributions |
| Form8282 Property Disposed Of | 0 | Form8282PropertyDisposedOf |
| Funds To Pay Premiums | 0 | FundsToPayPremiums |
| Premiums Paid | 0 | PremiumsPaid |
| Form8899 Filed | 0 | Form8899Filed |
| Form1098 C Filed | 0 | Form1098CFiled |
| Indoor Tanning Services | 0 | IndoorTanningServices |
| Info In Schedule O Part VI | X | InfoInScheduleOPartVI |
| Nbr Voting Governing Body Members | 5 | NbrVotingGoverningBodyMembers |
| Number Independent Voting Members | 5 | NumberIndependentVotingMembers |
| Family Or Business Relationship | 0 | FamilyOrBusinessRelationship |
| Delegation Of Management Duties | 0 | DelegationOfManagementDuties |
| Changes To Organizing Docs | 0 | ChangesToOrganizingDocs |
| Material Diversion Or Misuse | 0 | MaterialDiversionOrMisuse |
| Members Or Stockholders | 0 | MembersOrStockholders |
| Election Of Board Members | 0 | ElectionOfBoardMembers |
| Decisions Subject To Approval | 0 | DecisionsSubjectToApproval |
| Minutes Of Governing Body | 1 | MinutesOfGoverningBody |
| Minutes Of Committees | 0 | MinutesOfCommittees |
| Officer Mailing Address | 0 | OfficerMailingAddress |
| Local Chapters | 0 | LocalChapters |
| Form990 Provided To Governing Body | 1 | Form990ProvidedToGoverningBody |
| Conflict Of Interest Policy | 1 | ConflictOfInterestPolicy |
| Annual Disclosure Covered Persons | 1 | AnnualDisclosureCoveredPersons |
| Regular Monitoring Enforcement | 1 | RegularMonitoringEnforcement |
| Whistleblower Policy | 0 | WhistleblowerPolicy |
| Document Retention Policy | 1 | DocumentRetentionPolicy |
| Compensation Process CEO | 1 | CompensationProcessCEO |
| Compensation Process Other | 0 | CompensationProcessOther |
| Investment In Joint Venture | 0 | InvestmentInJointVenture |
| States Where Copy Of Return Is Filed | TX | StatesWhereCopyOfReturnIsFiled |
| Upon Request | X | UponRequest |
The Books Are In Care Of TheBooksAreInCareOf
Name Business NameBusiness
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | BELLVILLE GENERAL HOSPITAL | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Telephone Number | 9794137400 | TelephoneNumber |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 44 NORTH CUMMINGS | AddressLine1 |
| City | BELLVILLE | City |
| State | TX | State |
| ZIP Code | 77418 | ZIPCode |
Form990 Part VII Section A Form990PartVIISectionA (8 entries)
| TitleTitle | Average Hours Per WeekAverageHoursPerWeek | Individual Trustee Or DirectorIndividualTrusteeOrDirector | Reportable Comp From OrganizationReportableCompFromOrganization | Reportable Comp From Related OrgsReportableCompFromRelatedOrgs | Other CompensationOtherCompensation | OfficerOfficer |
|---|---|---|---|---|---|---|
| JOHN GRUBE | ||||||
| PRESIDENT | 1.00 | X | 0 | 0 | 0 | |
| JOHN HARLE | ||||||
| VICE PRESIDENT | 1.00 | X | 0 | 0 | 0 | |
| STEVE LACKEY | ||||||
| SECRETARY | 1.00 | X | 0 | 0 | 0 | |
| KARA GALLE | ||||||
| BOARD MEMBER | 1.00 | X | 0 | 0 | 0 | |
| MIKE ALDREDGE | ||||||
| BOARD MEMBER | 1.00 | X | 0 | 0 | 0 | |
| MICHAEL MORRIS | ||||||
| CEO | 40.00 | 151365 | 0 | 22033 | X | |
| JAN WALKER | ||||||
| CFO | 40.00 | 71042 | 0 | 0 | X | |
| SHARON GLENTZER | ||||||
| DON | 40.00 | 93414 | 0 | 0 | X | |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | 315821 | TotalReportableCompFromOrg |
| Total Reportable Comp Frm Rltd Orgs | 0 | TotalReportableCompFrmRltdOrgs |
| Total Other Compensation | 22033 | TotalOtherCompensation |
| Number Individuals GT100 K | 1 | NumberIndividualsGT100K |
| Formers Listed | 0 | FormersListed |
| Total Comp GT150 K | 1 | TotalCompGT150K |
| Compensation From Other Sources | 0 | CompensationFromOtherSources |
Contractor Compensation ContractorCompensation (5 entries)
| Address Line1AddressOfContractor/AddressUS/AddressLine1 | CityAddressOfContractor/AddressUS/City | StateAddressOfContractor/AddressUS/State | ZIP CodeAddressOfContractor/AddressUS/ZIPCode | Description Of ServicesDescriptionOfServices | CompensationCompensation |
|---|---|---|---|---|---|
| CONCORD MEDICAL GROUP | |||||
| PO BOX 489 | MULESHOE | TX | 79347 | PHYSICIAN SERVICES | 445142 |
| OUTSOURCED RECEIVABLES MANAGEMENT | |||||
| PO BOX 8621 | CORPUS CHRISTI | TX | 78468 | A/R BILLING AND COLLECTION SERVICES | 198791 |
| HUNTER PHARMACY SERVICES | |||||
| PO BOX 30573 | AUSTIN | TX | 78755 | PHARMACY MANAGEMENT | 164994 |
| WILLFORD V MORRIS JR DO PA | |||||
| 3433 HWY 36 SOUTH | SEALY | TX | 77474 | CLINIC PHYSICIAN | 128000 |
| DMS IMAGING INC | |||||
| 415 LOCKHAVEN DR | HOUSTON | TX | 77073 | MRI SERVICES | 117699 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Number Of Contractors GT100 K | 5 | NumberOfContractorsGT100K |
| All Other Contributions | 243105 | AllOtherContributions |
| Total Contributions | 243105 | TotalContributions |
Program Service Revenue ProgramServiceRevenue (2 entries)
| DescriptionDescription | Business CodeBusinessCode | Total Revenue ColumnTotalRevenueColumn | Related Or Exempt Function IncomeRelatedOrExemptFunctionIncome |
|---|---|---|---|
| PATIENT REVENUES, NET | 621990 | 7199426 | 7199426 |
| INDIGENT CARE SUPPORT | 621990 | 2461553 | 2461553 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | 9660979 | TotalProgramServiceRevenue |
Investment Income InvestmentIncome
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 1465 | TotalRevenueColumn |
| Exclusion | $1,465 | ExclusionAmount |
Gross Rents GrossRents
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | 249179 | Real |
Less Rental Expenses LessRentalExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | 176960 | Real |
Rental Income Or Loss RentalIncomeOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | 72219 | Real |
Net Rental Income Or Loss NetRentalIncomeOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 72219 | TotalRevenueColumn |
| Related Or Exempt Function Income | 72219 | RelatedOrExemptFunctionIncome |
Other Revenue Misc OtherRevenueMisc (3 entries)
| DescriptionDescription | Business CodeBusinessCode | Total Revenue ColumnTotalRevenueColumn | Related Or Exempt Function IncomeRelatedOrExemptFunctionIncome |
|---|---|---|---|
| MISCELLANEOUS INCOME | 900099 | 278582 | 278582 |
| CAFETERIA SALES | 900099 | 16114 | 16114 |
| REBATES | 900099 | 14549 | 14549 |
Miscellaneous Revenue MiscellaneousRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 6841 | TotalRevenueColumn |
| Related Or Exempt Function Income | 6841 | RelatedOrExemptFunctionIncome |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Other Revenue | 316086 | TotalOtherRevenue |
Total Revenue TotalRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 10293854 | TotalRevenueColumn |
| Related Or Exempt Function Income | 10049284 | RelatedOrExemptFunctionIncome |
| Unrelated Business Revenue | 0 | UnrelatedBusinessRevenue |
| Exclusion | $1,465 | ExclusionAmount |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part IX | X | InfoInScheduleOPartIX |
Other Salaries And Wages OtherSalariesAndWages
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 3961967 | Total |
| Program Services | 3386859 | ProgramServices |
| Management And General | 575108 | ManagementAndGeneral |
Pension Plan Contributions PensionPlanContributions
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 28886 | Total |
| Program Services | 28886 | ProgramServices |
Other Employee Benefits OtherEmployeeBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 1038848 | Total |
| Program Services | 726667 | ProgramServices |
| Management And General | 312181 | ManagementAndGeneral |
Fees For Services Legal FeesForServicesLegal
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 14390 | Total |
| Management And General | 14390 | ManagementAndGeneral |
Fees For Services Accounting FeesForServicesAccounting
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 66547 | Total |
| Management And General | 66547 | ManagementAndGeneral |
Fees For Services Other FeesForServicesOther
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 1548723 | Total |
| Program Services | 1281888 | ProgramServices |
| Management And General | 266835 | ManagementAndGeneral |
Advertising Advertising
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 26803 | Total |
| Program Services | 427 | ProgramServices |
| Management And General | 26376 | ManagementAndGeneral |
Office Expenses OfficeExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 407929 | Total |
| Program Services | 347376 | ProgramServices |
| Management And General | 60553 | ManagementAndGeneral |
Information Technology InformationTechnology
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 23152 | Total |
| Program Services | 23152 | ProgramServices |
Occupancy Occupancy
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 1901249 | Total |
| Program Services | 1867142 | ProgramServices |
| Management And General | 34107 | ManagementAndGeneral |
Travel Travel
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 55848 | Total |
| Program Services | 13084 | ProgramServices |
| Management And General | 42764 | ManagementAndGeneral |
Conferences Meetings ConferencesMeetings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 20143 | Total |
| Program Services | 12667 | ProgramServices |
| Management And General | 7476 | ManagementAndGeneral |
Interest Interest
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 182 | Total |
| Management And General | 182 | ManagementAndGeneral |
Insurance Insurance
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 54118 | Total |
| Management And General | 54118 | ManagementAndGeneral |
Other Expenses OtherExpenses (4 entries)
| DescriptionDescription | TotalTotal | Program ServicesProgramServices | Management And GeneralManagementAndGeneral |
|---|---|---|---|
| BAD DEBT | 1562712 | 1562712 | |
| MEDICAL SUPPLIES | 1028951 | 1017990 | 10961 |
| DUES & SUBSCRIPTIONS | 27642 | 10509 | 17133 |
| LICENSE & FEES | 20142 | 13935 | 6207 |
All Other Expenses AllOtherExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 24283 | Total |
| Program Services | 1832 | ProgramServices |
| Management And General | 22451 | ManagementAndGeneral |
Total Functional Expenses TotalFunctionalExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 11812515 | Total |
| Program Services | 10295126 | ProgramServices |
| Management And General | 1517389 | ManagementAndGeneral |
| Fundraising | 0 | Fundraising |
Cash Non Interest Bearing CashNonInterestBearing
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 868052 | BOY |
| EOY | 179352 | EOY |
Accounts Receivable AccountsReceivable
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 749552 | BOY |
| EOY | 759389 | EOY |
Inventories For Sale Or Use InventoriesForSaleOrUse
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 237492 | BOY |
| EOY | 249855 | EOY |
Prepaid Expenses Deferred Charges PrepaidExpensesDeferredCharges
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 44033 | BOY |
| EOY | 51583 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Buildings Equipment Basis | 2274977 | LandBuildingsEquipmentBasis |
| Land Bldg Equipment Accum Deprec | 107319 | LandBldgEquipmentAccumDeprec |
Land Buildings Equipment Basis Net LandBuildingsEquipmentBasisNet
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 272171 | BOY |
| EOY | 2167658 | EOY |
Other Assets Total OtherAssetsTotal
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 80210 | BOY |
| EOY | 256161 | EOY |
Total Assets TotalAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 2251510 | BOY |
| EOY | 3663998 | EOY |
Accounts Payable Accrued Expenses AccountsPayableAccruedExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 999288 | BOY |
| EOY | 2274112 | EOY |
Mort Notes Pybl Secured Invest Prop MortNotesPyblSecuredInvestProp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 200000 | BOY |
| EOY | 1856325 | EOY |
Total Liabilities TotalLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 1199288 | BOY |
| EOY | 4130437 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Follow SFAS117 | X | FollowSFAS117 |
Unrestricted Net Assets UnrestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 1052222 | BOY |
| EOY | -466439 | EOY |
Total Net Assets Fund Balances TotalNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 1052222 | BOY |
| EOY | -466439 | EOY |
Total Liab Net Assets Fund Balances TotalLiabNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 2251510 | BOY |
| EOY | 3663998 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Reconcilation Revenue Expenses | -1518661 | ReconcilationRevenueExpenses |
| Reconcilation Other Changes | 0 | ReconcilationOtherChanges |
| Method Of Accounting Accrual | X | MethodOfAccountingAccrual |
| Accountant Compile Or Review | 0 | AccountantCompileOrReview |
| FS Audited | 0 | FSAudited |
| Federal Grant Audit Required | 0 | FederalGrantAuditRequired |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Hospital170b1 Aiii | X | Hospital170b1Aiii |
Schedule B IRS990ScheduleB
Contributor Info ContributorInfo
| Field | Value | IRS element (for citing) |
|---|---|---|
| Contributor Number | RESTRICTED | ContributorNumber |
Contributor Name Business ContributorNameBusiness
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | RESTRICTED | BusinessNameLine1 |
Contributor Address US ContributorAddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | RESTRICTED | AddressLine1 |
| Address Line2 | RESTRICTED | AddressLine2 |
| City | RESTRICTED | City |
| State | RESTRICTED | State |
| ZIP Code | RESTRICTED | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Aggregate Contributions | RESTRICTED | AggregateContributions |
Schedule D IRS990ScheduleD
Buildings Buildings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 3897 | OtherCostOrOtherBasis |
| Book Value | 3897 | BookValue |
Leasehold Improvements LeaseholdImprovements
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 16516 | OtherCostOrOtherBasis |
| Book Value | 16516 | BookValue |
Equipment Equipment
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 2254564 | OtherCostOrOtherBasis |
| Depreciation | 107319 | Depreciation |
| Book Value | 2147245 | BookValue |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Book Value Land Buildings | 2167658 | TotalOfBookValueLandBuildings |
Other Assets OtherAssets (3 entries)
| DescriptionDescription | Book ValueBookValue |
|---|---|
| RENT RECEIVABLE | 900 |
| MEDICARE & MEDICAID COST REPORT RECEIVABLE | 39789 |
| UNCOMPENSATED CARE RECEIVABLE | 215472 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Other Assets | 256161 | TotalBookValueOtherAssets |
| Footnote In Part XIII | X | FootnoteInPartXIII |
| Tot Revenue Etc Audited Fincl Stmt | 8908102 | TotRevenueEtcAuditedFinclStmt |
| Other Revenues | 176960 | OtherRevenues |
| Revenue Not Rptd F990 | 176960 | RevenueNotRptdF990 |
| Revenue Subtotal | 8731142 | RevenueSubtotal |
| Other Revenues Not Included | 1562712 | OtherRevenuesNotIncluded |
| Revenue Not Rptd On Fin Stmt | 1562712 | RevenueNotRptdOnFinStmt |
| Total Revenue Per Form990 | 10293854 | TotalRevenuePerForm990 |
| Tot Expenses Etc Audited Fincl Stmt | 10426763 | TotExpensesEtcAuditedFinclStmt |
| Other Expenses Included | 176960 | OtherExpensesIncluded |
| Expenses Not Rptd F990 | 176960 | ExpensesNotRptdF990 |
| Expenses Subtotal | 10249803 | ExpensesSubtotal |
| Other Expenses Not Included | 1562712 | OtherExpensesNotIncluded |
| Expenses Not Rptd On Fin Stmt | 1562712 | ExpensesNotRptdOnFinStmt |
| Total Expenses Per Form990 | 11812515 | TotalExpensesPerForm990 |
Form990 Schedule D Part XIII Form990ScheduleDPartXIII (5 entries)
| IdentifierIdentifier | Return ReferenceReturnReference | ExplanationExplanation |
|---|---|---|
| DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: | PART X, LINE 2: | THE HOSPITAL IS A NOT-FOR-PROFIT ORGANIZATION THAT IS EXEMPT FROM INCOME TAXES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. THE HOSPITAL EVALUATES AND ACCOUNTS FOR UNCERTAIN TAX POSITIONS IN ACCORDANCE WITH FINANCIAL ACCOUNTING STANDARDS BOARD (FASB) ACCOUNTING STANDARDS CODIFICATION (ASC) 740, INCOME TAXES (FORMERLY FASB INTERPRETATION 48 (FIN 48) ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES. THIS STANDARD REQUIRES CERTAIN DISCLOSURES ABOUT UNCERTAIN INCOME TAX POSITIONS. THE HOSPITAL EVALUATES ANY UNCERTAIN TAX POSITIONS USING THE PROVISIONS OF ASC 450, CONTINGENCIES. AS A RESULT, MANAGEMENT DOES NOT BELIEVE THAT ANY UNCERTAIN TAX POSITIONS CURRENTLY EXIST AND NO LOSS CONTINGENCY HAS BEEN RECOGNIZED IN THE ACCOMPANYING FINANCIAL STATEMENTS. THE HOSPITAL HAS FILED ALL APPLICABLE TAX RETURNS. |
| PART XI, LINE 2D - OTHER ADJUSTMENTS: | RENTAL EXPENSES 176,960. | |
| PART XI, LINE 4B - OTHER ADJUSTMENTS: | BAD DEBT EXPENSE 1,562,712. | |
| PART XII, LINE 2D - OTHER ADJUSTMENTS: | RENTAL EXPENSES 176,960. | |
| PART XII, LINE 4B - OTHER ADJUSTMENTS: | BAD DEBT EXPENSE 1,562,712. |
Schedule H IRS990ScheduleH
| Field | Value | IRS element (for citing) |
|---|---|---|
| Charity Care Policy | 1 | CharityCarePolicy |
| Written Policy | 1 | WrittenPolicy |
| Policy Applied To All Hospitals | X | PolicyAppliedToAllHospitals |
| FPG Reference Free Care | 1 | FPGReferenceFreeCare |
| Pcent200 | X | Pcent200 |
| FPG Reference Discounted Care | 1 | FPGReferenceDiscountedCare |
Discounted Other DiscountedOther
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | X | Other |
| Discounted Other Percentage | 500.000000000000 | DiscountedOtherPercentage |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Free Disc Care Medically Indigent | 1 | FreeDiscCareMedicallyIndigent |
| Amounts Budgeted For Charity Care | 1 | AmountsBudgetedForCharityCare |
| Expenses Exceeded Budget | 0 | ExpensesExceededBudget |
| Annual Community Benefit Report | 1 | AnnualCommunityBenefitReport |
| Report Publically Available | 1 | ReportPublicallyAvailable |
Charity Care At Cost CharityCareAtCost
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 391805 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 266599 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 125206 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.01220 | PercentOfTotalExpense |
Unreimbursed Medicaid UnreimbursedMedicaid
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 2224605 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 2110901 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 113704 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.01110 | PercentOfTotalExpense |
Unreimbursed Costs UnreimbursedCosts
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 112605 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 106812 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 5793 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00060 | PercentOfTotalExpense |
Total Charity Care TotalCharityCare
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 2729015 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 2484312 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 244703 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.02390 | PercentOfTotalExpense |
Total Community Benefits TotalCommunityBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 2729015 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 2484312 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 244703 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.02390 | PercentOfTotalExpense |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | 1 | BadDebtExpenseReported |
| Bad Debt Expense | $773,731 | BadDebtExpenseAmount |
| Amount Attributable To | 541128 | AmountAttributableTo |
| Amount Reimbursed By Medicare | 2085476 | AmountReimbursedByMedicare |
| Cost Of Care Reimbursed By Medicare | 658982 | CostOfCareReimbursedByMedicare |
| Medicare Surplus Or Shortfall | 1426494 | MedicareSurplusOrShortfall |
Costing Methodology Used CostingMethodologyUsed
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cost To Charge Ratio | X | CostToChargeRatio |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Written Debt Collection Policy | 1 | WrittenDebtCollectionPolicy |
| Provision For Charity Care | 1 | ProvisionForCharityCare |
| Number Of Hospital Facilities | 1 | NumberOfHospitalFacilities |
Form990 Schedule H Part V Section A Form990ScheduleHPartVSectionA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility Number | 1 | FacilityNumber |
Name Name
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | BELLVILLE GENERAL HOSPITAL | BusinessNameLine1 |
Address Address
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 44 N CUMMINGS | AddressLine1 |
| City | BELLVILLE | City |
| State | TX | State |
| ZIP Code | 77418 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Licensed Hospital | X | LicensedHospital |
| General Medical And Surgical | X | GeneralMedicalAndSurgical |
| Er24 Hours | X | Er24Hours |
| Other | HOSPITAL | Other |
Form990 Schedule H Part V Section B Form990ScheduleHPartVSectionB
Hospital Facility Name HospitalFacilityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | BELLVILLE GENERAL HOSPITAL | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Hospital Facility Number | 1 | HospitalFacilityNumber |
| CHNA Conducted | 0 | CHNAConducted |
| Eligibility Criteria Explained | 1 | EligibilityCriteriaExplained |
| Uses FPG Free | 1 | UsesFPGFree |
| FPG Free Percent | 200.000000000000 | FPGFreePercent |
| Uses FPG Discounted | 1 | UsesFPGDiscounted |
| FPG Discount Percent | 500.000000000000 | FPGDiscountPercent |
| Explains Basis | 1 | ExplainsBasis |
| Income Level | X | IncomeLevel |
| Medical Indigency | X | MedicalIndigency |
| Insurance Status | X | InsuranceStatus |
| Other Factors | X | OtherFactors |
| Explains Application Method | 1 | ExplainsApplicationMethod |
| Includes Publicity Measures | 1 | IncludesPublicityMeasures |
| Posted On Website | X | PostedOnWebsite |
| Posted In Emergency Room | X | PostedInEmergencyRoom |
| Posted In Admission Office | X | PostedInAdmissionOffice |
| Available On Request | X | AvailableOnRequest |
| Other Publicity | X | OtherPublicity |
| Actions On Nonpayment | 0 | ActionsOnNonpayment |
| Collection Activities | 0 | CollectionActivities |
| Nondiscrim Emergency Care Policy | 0 | NondiscrimEmergencyCarePolicy |
| No Emergency Policy | X | NoEmergencyPolicy |
| Amounts Generally Billed | 0 | AmountsGenerallyBilled |
| Gross Charges | 0 | GrossCharges |
Form990 Schedule H Part V Section C Form990ScheduleHPartVSectionC
| Field | Value | IRS element (for citing) |
|---|---|---|
| Number Of Other Facilities | 1 | NumberOfOtherFacilities |
Other Facilities OtherFacilities
Name Name
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | MEDICAL CLINIC OF BELLVILLE | BusinessNameLine1 |
Address Address
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 235 W PALM SUITE 108 | AddressLine1 |
| City | BELLVILLE | City |
| State | TX | State |
| ZIP Code | 77418 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility Type | RURAL HEALTH CLINIC | FacilityType |
Form990 Schedule H Part VI Form990ScheduleHPartVI (12 entries)
| ExplanationExplanation | IdentifierIdentifier |
|---|---|
| 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 $ 1562712. | |
| PART III, LINE 4: THE ALLOWANCE FOR ESTIMATED UNCOLLECTIBLE PATIENT ACCOUNTS RECEIVABLE IS MAINTAINED AT A LEVEL WHICH, IN MANAGEMENT'S JUDGMENT, IS ADEQUATE TO ABSORB PATIENT ACCOUNT BALANCE WRITE-OFFS INHERENT IN THE BILLING PROCESS. THE AMOUNT OF THE ALLOWANCE IS BASED ON MANAGEMENT EVALUATION OF THE COLLECTIBILITY OF PATIENT ACCOUNTS RECEIVABLE, INCLUDING THE NATURE OF THE ACCOUNTS, CREDIT CONCENTRATIONS, HISTORICAL WRITE-OFF TRENDS, SPECIFIC IMPAIRED ACCOUNTS, AND ECONOMIC CONDITIONS. ALLOWANCES FOR UNCOLLECTIBLE AND CONTRACTUALS ARE GENERALLY DETERMINED BY APPLYING HISTORICAL PERCENTAGES TO FINANCIAL CLASSES WITHIN ACCOUNTS RECEIVABLE. THE ALLOWANCES ARE INCREASED BY A PROVISION FOR BAD DEBT EXPENSES AND CONTRACTUAL ADJUSTEMENTS, AND REDUCED BY WRITE-OFFS, NET OF RECOVERIES. | |
| PART III, LINE 8: LINE 6 IS ARRIVED BY USING THE COST TO CHARGE RATIOS BASED ON THE MEDICARE COST REPORT.LINE 7 SHOULD BE TREATED AS A COMMUNITY BENEFIT IN THAT THE HOSPITAL TREATS PATIENTS REGARDLESS OF THE REIMBURSEMENT BY MEDICARE. | |
| PART III, LINE 9B: THE DEBT COLLECTION POLICY PROVIDES A PROVISION THAT EXCLUDES THOSE WHO QUALIFY FOR CHARITY FROM EVER BEING A PART OF THE BAD DEBT. | |
| PART V, SECTION B, LINE 10: A FINANCIALLY INDIGENT PATIENT IS A PERSON WHO IS UNINSURED OR UNDERINSURED AND IS ACCEPTED FOR CARE WITH NO OBLIGATION OR A DISCOUNTED OBLIGATION TO PAY FOR SERVICES RENDERED BASED ON THE HOSPITAL'S ELIGIBILITY CRITERIA. TO BE ELIGIBLE FOR CHARITY CARE AS A FINANCIALLY INDIGENT PATIENT, A PERSON'S GROSS ANNUAL INCOME SHALL BE AT OR BELOW 200 PERCENT OF THE FEDERAL POVERTY GUIDELINES AND HAVE NO ALTERNATIVE RESOURCES AVAILABLE. HOSPITAL MAY CONSIDER OTHER FINANCIAL ASSETS AND LIABILITIES OF THE PERSON WHEN DETERMINING ELIGIBILITY. | BELLVILLE GENERAL HOSPITAL |
| PART V, SECTION B, LINE 11: A MEDICALLY INDIGENT PATIENT IS A PERSON WHO'S MEDICAL OR HOSPITAL BILLS AFTER PAYMENT BY THIRD-PARTY PAYERS EXCEED A SPECIFIC PERCENTAGE OF THE PERSON'S ANNUAL GROSS INCOME AND WHO IS UNABLE TO PAY THE REMAINING BILL. THE HOSPITAL MAY CONSIDER OTHER ASSETS AND LIABILITIES OF THE PERSON WHEN DETERMINING ABILITY TO PAY. TO BE ELIGIBLE FOR CHARITY CARE AS A MEDICALLY INDIGENT PATIENT, THE PATIENT'S GROSS ANNUAL INCOME MUST BE GREATER THAN 200 PERCENT BUT LESS THAN OR EQUAL TO 500 PERCENT OF THE FEDERAL POVERTY LEVEL AND THE AMOUNT OWED BY THE PATIENT ON THE HOSPITAL BILL AFTER PAYMENT BY THIRD PARTY PAYERS MUST EXCEED 10 PERCENT OF THE PATIENT'S GROSS ANNUAL INCOME. IN THESE INSTANCES, THE HOSPITAL MAY DETERMINE THE AMOUNT OF FINANCIAL ASSISTANCE GRANTED TO THESE PATIENTS AS SET FORTH IN THE HOSPITAL'S FINANCIAL ASSISTANCE ELIGIBILITY DISCOUNT GUIDELINES. TO QUALIFY AS CATASTROPHIC MEDICAL INDIGENCE, THE PATIENT'S REMAINING BILL MUST BE NO GREATER THAN 50 PERCENT OF THE PATIENT'S GROSS ANNUAL INCOME AND THE PATIENT'S INCOME MUST BE GREATER THAN 500 PERCENT OF THE FEDERAL POVERTY GUIDELINES. IN THESE INSTANCES, THE HOSPITAL MAY DETERMINE THE AMOUNT OF FINANCIAL ASSISTANCE GRANTED TO THESE PATIENTS IN ACCORDANCE WITH THE HOSPITAL'S FINANCIAL ASSISTANCE ELIGIBILITY DISCOUNT GUIDELINES. A DETERMINATION OF A PATIENT'S ABILITY TO PAY THE REMAINDER OF THE BILL WILL BE BASED ON WHETHER THE PATIENT CAN REASONABLY BE EXPECTED TO PAY THE ACCOUNT IN FULL OVER A TWO-YEAR PERIOD. IF A DETERMINATION IS MADE THAT A PATIENT HAS THE ABILITY TO PAY THE REMAINDER OF THE BILL, SUCH A DETERMINATION DOES NOT PREVENT A RE-ASSESSMENT OF THE PATIENT'S ABILITY TO PAY AT A LATER DATE. | BELLVILLE GENERAL HOSPITAL |
| PART V, SECTION B, LINE 12H: THE HOSPITAL IS A NOT FOR PROFIT CORPORATION OFFERING A CHARITY CARE PROGRAM. THE HOSPITAL WILL NOT DISCRIMINATE ON THE BASIS OF RACE, ANCESTRY, RELIGION, NATIONAL ORIGIN, CITIZENSHIP STATUS, AGE, DISABILITY, OR GENDER IN ITS CONSIDERATION OF A PATIENT'S QUALIFICATION FOR CHARITY CARE. THE CLASSIFICATION OF A PATIENT AS BEING ELIGIBLE FOR CHARITY CARE SHALL OCCUR AT THE TIME SUFFICIENT INFORMATION HAS BEEN OBTAINED TO VERIFY THE PATIENT'S INABILITY TO PAY FOR NEEDED MEDICAL SERVICES, AND AS SOON AS POSSIBLE AFTER THE PATIENT FIRST PRESENTS FOR SERVICES OR INDICATES AN INABILITY TO PAY FOR SERVICES. THIS PATIENT'S IDENTIFICATION PROCESS INCLUDES PATIENTS WITH THIRD PARTY COVERAGE (I.E., INSURANCE, MEDICARE, ETC.) WHERE THE PATIENT HAS A RESPONSIBILITY FOR PAYMENT AND HAS AN INABILITY TO PAY.THE HOSPITAL PERSONNEL SHALL ATTEMPT TO IDENTIFY ALL CASES THAT QUALIFY AS CHARITY PATIENTS AT THE TIME OF PRE-REGISTRATION OR ADMISSION. PATIENTS IDENTIFIED AS POSSIBLE CHARITY CARE PATIENTS WILL BE GIVEN AN APPLICATION AND POLICY GUIDELINES TOGETHER WITH DIRECTIONS ON COMPLETING THE PAPER WORK AND ANY ADDITIONAL DOCUMENTATION NEEDED TO CONSIDER THE APPLICATION. THE PATIENT WILL ALSO BE GIVEN CONTACT INFORMATION FOR THE APPROPRIATE PERSONNEL TO WHOM THEY SHOULD RETURN THE APPLICATION.APPLICANTS MUST FULLY COOPERATE AND COMPLY WITH ELIGIBILITY REQUIREMENTS FOR ANY OTHER HEALTHCARE PROGRAM(S) FOR WHICH THEY MAY BE QUALIFIED PRIOR TO THEIR EVALUATION FOR CHARITY CARE. FEDERAL AND/OR STATE ASSISTANCE MAY BE AVAILABLE TO THOSE WHO MEET QUALIFICATIONS. BEFORE CHARITY CARE IS CONSIDERED, ALL AVAILABLE AVENUES OF ASSISTANCE FROM THIRD-PARTY PAYORS MUST BE EXHAUSTED.ALL SERVICES MUST BE MEDICALLY NECESSARY IN ORDER TO QUALIFY FOR A CHARITY CARE DISCOUNT (E.G., ELECTIVE PROCEDURES SUCH AS COSMETIC SURGERY DO NOT QUALIFY FOR A CHARITY DESIGNATION). ELIGIBLE SERVICES WILL BE BASED ON THOSE SERVICES FOR WHICH MEDICARE PROVIDES COVERAGE. PATIENTS OR THE RESPONSIBLE PARTY MUST VERIFY THE INCOME REPORTED ON THE FINANCIAL ASSISTANCE APPLICATION IN ACCORDANCE WITH THE DOCUMENTATION REQUIREMENTS SET FORTH BELOW:A. IN ORDER TO BE CONSIDERED FOR CHARITY CARE, CREDIT REPORT AND INCOME INFORMATION MAY BE OBTAINED REGARDING THE PATIENT. HOSPITAL MAY OBTAIN A CREDIT REPORT ON PATIENTS TO CONFIRM THE INCOME DOCUMENTATION PATIENT PROVIDES. ELIGIBILITY DOCUMENTATION MUST BE MAINTAINED IN THE PATIENT'S FINANCIAL FILE IN ADDITION TO THE CREDIT REPORT. THE HOSPITAL MAY OBTAIN, FOR EACH PATIENT, ONE OR MORE OF THE FOLLOWING DOCUMENTS IN ORDER TO DETERMINE INCOME AND ASSETS OF THE PATIENT.I. IRS FORM W-2;II. WAGE AND EARNINGS STATEMENT;III. PAYCHECK REMITTANCE;IV. INDIVIDUAL TAX RETURNS;V. UNEMPLOYMENT INSURANCE;VI. SOCIAL SECURITY AWARD LETTER, OR COPY OF SOCIAL SECURITY CHECK;VII. TELEPHONE VERIFICATION BY EMPLOYER OF THE PATIENTS INCOME;VIII. VETERAN'S ADMINISTRATION LETTER, OR COPY OF VA CHECK;IX. PHYSICIAN DISABILITY STATEMENT LISTING TERM OF DISABILITY AND DOCUMENTATION OR PROOF OF THREE OR MORE MONTHS WITH NO INCOME FOR THE PERIOD OF DISABILITY;X. BANK ACCOUNTS AND RECORDS; ORXI. OTHER APPROPRIATE INDICATORS OF YEARLY, MONTHLY, WEEKLY, OR HOURLY INCOME.B. BY THE PROVISION OF DOCUMENTATION SHOWING CURRENT PARTICIPATION IN A PUBLIC BENEFIT PROGRAM SUCH AS WORKER'S COMPENSATION, MEDICAID, COUNTY INDIGENT HEALTH PROGRAM, TANF, WIC, TEXAS HEALTHY KIDS, CHILDREN'S HEALTH INSURANCE PROGRAM, UNEMPLOYMENT COMPENSATION DETERMINATION LETTER, UNEMPLOYMENT INSURANCE, OR OTHER SIMILAR INDIGENCY-RELATED PROGRAMS. PROOF OF PARTICIPATION IN ANY OF THE ABOVE PROGRAMS INDICATES THAT THE PATIENT HAS BEEN DEEMED FINANCIALLY INDIGENT AND THEREFORE, IS NOT REQUIRED TO PROVIDE HIS OR HER "GROSS MONTHLY INCOME" OF THE FINANCIAL ASSISTANCE APPLICATION, OR PROVIDE ANY OF THE INCOME DOCUMENTATION VERIFICATION LISTED ABOVE. THE HOSPITAL MAY ALSO USE THIRD-PARTY VERIFICATION OF A PATIENT'S PARTICIPATION IN A PUBLIC BENEFIT PROGRAM IF THE CHARITY CARE APPLICANT IS UNABLE TO PROVIDE THAT DOCUMENTATION. | BELLVILLE GENERAL HOSPITAL |
| PART V, SECTION B, LINE 14G: THE HOSPITAL'S CHARITY CARE DISCOUNT POLICY MUST BE AVAILABLE TO THE PUBLIC. IN ADDITION TO THE PROMINENT POSTING OF A CHARITY CARE NOTICE IN THE ADMISSIONS AND EMERGENCY ROOM AREA, A COPY OF THE CHARITY CARE DISCOUNT POLICY SHOULD BE DISSEMINATED TO ALL PATIENTS WHO REQUEST IT. | BELLVILLE GENERAL HOSPITAL |
| PART VI, LINE 2: NEEDS OF THE COMMUNITY ARE ASSESSED BY GEOGRAPHIC INFORMATION AVAILABLE TO THE HOSPITAL, STATISTICAL INFORMATION THAT THE HOSPITAL CAN USE TO FURTHER IT'S BENEFIT TO THE COMMUNITY. | |
| PART VI, LINE 3: THERE ARE SEVERAL WAYS THAT THE HOSPITAL EDUCATES THE PUBLIC ABOUT ITS CHARITY CARE PROGRAMS. THE WEBSITE PROVIDES A PHONE NUMBER TO CONTACT A BUSINESS OFFICE REPRESENTATIVE FOR ASSISTANCE. THERE ARE ALSO SIGNS IN BOTH ENGLISH AND SPANISH THAT DIRECT PATIENTS TO THE ASSISTANCE THEY COULD QUALIFY FOR. | |
| PART VI, LINE 4: BELLVILLE GENERAL HOSPITAL SERVES BELLVILLE AND THE SURROUNDING COMMNUITIES WITHIN AUSTIN COUNTY. 24,893 OR 87.6% OF THE 28,417 PEOPLE LIVING IN AUSTIN COUNTY ARE WHITE ACCORDING TO THE LATEST CENSUS. BELLVILLE GENERAL HOSPITAL IS LOCATED IN BELLVILLE WHICH IS APPROXIMATELY 60 MILES WEST OF HOUSTON. AS OF THE LATEST CENSUS, MEDIAN HOUSEHOLD INCOME WAS $53,263. 8.8% OF PERSONS WERE BELOW THE POVERTY LINE. | |
| PART VI, LINE 5: THE HOSPITAL OPERATES AS AN EXEMPT HOSPITAL AND PROVIDES INPATIENT AND OUTPATIENT SERVICES AS WELL AS OTHER AFFILIATED SERVICES TO THE COMMUNITY. |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Severance Payment | 0 | SeverancePayment |
| Supplemental Nonqual Retire Plan | 0 | SupplementalNonqualRetirePlan |
| Equity Based Comp Arrangement | 0 | EquityBasedCompArrangement |
| Comp Based On Revenue Of Filing Org | 0 | CompBasedOnRevenueOfFilingOrg |
| Comp Based On Revenue Related Orgs | 0 | CompBasedOnRevenueRelatedOrgs |
| Comp Based Net Earnings Filing Org | 0 | CompBasedNetEarningsFilingOrg |
| Comp Based Net Earnings Relate Orgs | 0 | CompBasedNetEarningsRelateOrgs |
| Any Non Fixed Payments | 0 | AnyNonFixedPayments |
| Initial Contract Exception | 0 | InitialContractException |
Form990 Schedule J Part II Form990ScheduleJPartII
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Person | MICHAEL MORRIS | NamePerson |
| Title | CEO | Title |
| Base Compensation Filing Org | 151365 | BaseCompensationFilingOrg |
| Comp Based On Related Orgs | 0 | CompBasedOnRelatedOrgs |
| Bonus Filing Org | 0 | BonusFilingOrg |
| Bonus Related Orgs | 0 | BonusRelatedOrgs |
| Other Compensation Filing Org | 0 | OtherCompensationFilingOrg |
| Other Compensation Related Orgs | 0 | OtherCompensationRelatedOrgs |
| Deferred Comp Filing Org | 22033 | DeferredCompFilingOrg |
| Deferred Comp Related Orgs | 0 | DeferredCompRelatedOrgs |
| Nontaxable Benefits Filing Org | 0 | NontaxableBenefitsFilingOrg |
| Nontaxable Benefits Related Orgs | 0 | NontaxableBenefitsRelatedOrgs |
| Total Compensation Filing Org | 173398 | TotalCompensationFilingOrg |
| Total Compensation Related Orgs | 0 | TotalCompensationRelatedOrgs |
| Comp Report Prior990 Filing Org | 0 | CompReportPrior990FilingOrg |
| Comp Report Prior990 Related Orgs | 0 | CompReportPrior990RelatedOrgs |
Schedule O IRS990ScheduleO
General Explanation GeneralExplanation (7 entries)
| Return ReferenceReturnReference | ExplanationExplanation | IdentifierIdentifier |
|---|---|---|
| FORM 990, PART VI, SECTION A, LINE 8B | THE ORGANIZATION DOES NOT HAVE COMMITTEES THAT ACT ON BEHALF OF THE GOVERNING BODY. | |
| FORM 990, PART VI, SECTION B, LINE 11 | THE ORGANIZATION'S TAX RETURN IS REVIEWED AND APPROVED BY MANAGEMENT. | |
| FORM 990, PART VI, SECTION B, LINE 11 | THE 990 IS REVIEWED AND APPROVED BY MANAGEMENT BEFORE PRESENTATION TO THE BOARD WHERE THE BOARD REVIEWS AND APPROVES THE FILING OF THE 990. | |
| FORM 990, PART VI, SECTION B, LINE 12C | BOARD MEMBERS ARE REQUIRED TO ANNUALLY DISCLOSE ANY CONFLICT OF INTEREST. | |
| FORM 990, PART VI, SECTION B, LINE 15A | AN EXECUTIVE COMMITTEE REVIEWS MANAGEMENT PERFORMANCE ANNUALLY AND MAY RECOMMEND A SALARY INCREASE TO THE BOARD OF DIRECTORS WHO THEN MAKES A DECISION. | |
| FORM 990, PART VI, SECTION C, LINE 19 | NO DOCUMENTS OTHER THAN THE 990 IS AVAILABLE TO THE PUBLIC. | |
| FORM 990, PART IX, LINE 11G | PROFESSIONAL & PHYSICIAN FEES: PROGRAM SERVICE EXPENSES 1,281,888. MANAGEMENT AND GENERAL EXPENSES 266,835. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,548,723. | OTHER FEES |