2013-12-23T13:32:17-06:00 2013-06-30 351178661 BLUE & CO LLC ONE AMERICAN SQUARE 2200 INDIANAPOLIS IN 46282 990 2012-07-01 350811197 FAIRBANKS HOSPITAL INC FAIR 3178498222 8102 CLEARVISTA PARKWAY INDIANAPOLIS IN 46256 MARK MONSON 3178498222 2013-12-20 1 AMBER KOCHER CPA P01286298 3176334705 2012 2015-11-30 17:44:51Z MARK MONSON 8102 CLEARVISTA PARKWAY INDIANAPOLIS IN 46256 22571143 0 X WWW.FAIRBANKSCD.ORG X 1946 IN NONPROFIT ORGANIZATION FOCUSED ON RECOVERY FROM ALCOHOL AND OTHER DRUG PROBLEMS. 17 16 350 150 0 0 1165001 3079335 19017562 17927665 23325 31015 1718986 1452082 21924874 22490097 0 0 0 0 13165601 13568081 0 0 184965 8114830 5792382 21280431 19360463 644443 3129634 23666521 26743154 1674854 1900664 21991667 24842490 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 8150420 0 9513987 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 8,744 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 3,388 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 1,444 ADULT RESIDENTIAL PATIENT DAYS. 3484371 0 4067307 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 7,893 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 12,763 VISITS. 1419021 0 1656424 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 612 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 876 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 1,997 ADOLESCENT RESIDENTIAL PATIENT DAYS. 2733599 0 3190929 ADOLESCENT OUTPATIENTS SERVICES PROGRAM SERVED 1,844 PHP VISITS AND 4,196 IOP VISITS DURING THE CURRENT FISCAL YEAR. ADULT HALFWAY HOUSE SERVED 1,273 PATIENT DAYS DURING THE CURRENT FISCAL YEAR. FAIRBANKS HOSPITAL PROVIDED 3,397 PATIENT DAYS AT LAVERNA LODGE AND PROVIDED 32,664 PATIENT DAYS AT SUPPORTED LIVING FACILITIES DURING THE CURRENT FISCAL YEAR. 2733599 3190929 15787411 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 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 26 0 1 350 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 VICE PRESIDENT AND 3175729450 8102 CLEARVISTA PARKWAY INDIANAPOLIS IN 46256 X RICHARD COLLINS 1.00 0.00 X X 0 0 0 THOMAS CRAIG 1.00 0.00 X X 0 0 0 TOM FLOWERS 1.00 0.00 X X 0 0 0 FARAZ ABBASI 1.00 0.00 X 0 0 0 TOM EMMERSON 1.00 0.00 X 0 0 0 JOHN HAYES MD 1.00 0.00 X 0 0 0 LUKE KENLEY 1.00 0.00 X 0 0 0 CAROL BROWN LUKEMEYER 1.00 0.00 X 0 0 0 PEGGY MAGEE 1.00 0.00 X 0 0 0 KARL STOUT 1.00 0.00 X 0 0 0 JANE WARDLE 1.00 0.00 X 0 0 0 PATRICK CARR 1.00 0.00 X 0 0 0 DAVID CORBITT 1.00 0.00 X 0 0 0 ANN MERKEL 1.00 0.00 X 0 0 0 KEVIN MURPHY 1.00 0.00 X 0 0 0 BEVERLY PITTS 1.00 0.00 X 0 0 0 LEAH MANNWEILER 1.00 0.00 X X 0 0 0 MARNI MCKINNEY 1.00 0.00 X 0 0 0 DOROTHY MAY 1.00 1.00 X 0 0 0 HELENE CROSS 38.40 1.60 X 389749 0 35481 MARK MONSON 38.40 1.60 X X 59207 0 5618 BARBARA ELLIOTT 36.00 4.00 X 116378 0 29320 TIMOTHY KELLY 32.00 0.00 X 186898 0 18485 CYNTHIA LEIGH 40.00 0.00 X 130271 0 714 DR DENNIS RHYNE 40.00 0.00 X 151245 0 3281 DR BARBARA DAVIS 40.00 0.00 X 146326 0 8356 SHARON BAKER 40.00 0.00 X 102528 0 7959 1282602 0 109214 7 0 1 0 SODEXO INC & AFFILIATES 4880 PAYSPHERE CIRCLE CHICAGO IL 60674 FOOD SERVICES MGMT 840989 PROGRESSIVE HOMECARE SERVICES PO BOX 6069-DEPT 178 INDIANAPOLIS IN 46206 PHARMACY SERVICES 305785 SOUTH BEND MEDICAL FOUNDATION PO BOX 2030 MISHAWAKA IN 46546 REFERRAL LAB SERVICE 279137 FA WILHELM CONSTRUCTION COMPANY PO BOX 516 INDIANAPOLIS IN 46206 CONSTRUCTION SERVICES 185605 COMMUNITY HEALTH NETWORK 1500 N RITTER AVENUE INDIANAPOLIS IN 46219 IT SERVICES 133894 5 73497 307827 2698011 3079335 PATIENT SERVICE REVENUE 621300 17927665 17927665 17927665 25515 25515 144600 0 144600 144600 144600 5500 0 5500 5500 5500 32770 73497 81046 -48276 -48276 OTHER REVENUE 900099 790289 790289 OUTSIDE COUNSELING SERVICES 624100 500982 500982 GIFT SHOP REVENUE 453220 64487 64487 1355758 22490097 18428647 0 982115 526389 193044 333345 9508290 7967215 1429332 111743 347752 291389 52276 4087 2384358 2001479 355195 27684 801292 671421 120454 9417 87148 87148 54778 54778 1783020 1291222 487354 4444 378978 369490 9079 409 166012 102127 63463 422 1113613 1060962 52651 58188 55587 1888 713 55525 32208 21085 2232 7432 7432 883700 814793 68907 246822 184783 60984 1055 SUPPLIES 598901 582931 15410 560 EQUIPMENT MAINTENANCE A 75138 63581 11557 0 PRINTING AND PUBLICATIO 51224 10880 32160 8184 POSTAGE AND SHIPPING 30568 17488 11323 1757 201335 69379 119698 12258 19360463 15787411 3388087 184965 1214354 1806354 6572961 6984631 109968 92363 3698498 3167912 455170 533664 22969973 9374065 11143927 13595908 471643 562322 23666521 26743154 1467989 1205997 490000 206865 204667 1674854 1900664 X 21742323 24618944 249344 223546 21991667 24842490 23666521 26743154 X 3129634 -278811 X X 0 1 X 1 1 1 X SCHEDULE A, PART IV, SUPPLEMENTAL INFORMATION: SCHEDULE A, PART I, LINE 3: 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 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 924344 2368777 2394575 898546 873382 440636 429 390103 924344 892895 391777 5733 417023 873382 979700 732482 47932 867219 892895 424006 1288061 67990 800357 979700 0.75120 0.00000 0.24880 0 0 768446 768446 12718595 5202254 7516341 6184940 4171811 2013129 3297992 3297992 13595908 ESTIMATED THIRD PARTY SETTLEMENTS 204667 204667 X 22571143 81046 81046 22490097 0 22490097 19441509 81046 81046 19360463 0 19360463 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: 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. 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 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, 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. PART XI, LINE 2D - OTHER ADJUSTMENTS: FUNDRAISING EVENT EXPENSES 81,046. PART XII, LINE 2D - OTHER ADJUSTMENTS: FUNDRAISING EVENT EXPENSES 81,046. CIRCLE OF HOPE DINNER 87787 60877 26910 7279 27144 10350 26667 ALUMNI GOLF OUTING 18480 12620 5860 2254 5723 122 1507 106267 73497 32770 2254 13002 27266 10350 28174 81046 -48276 1 1 0 1 X 0 1 0 1 0 907632 0 907632 0.04690 39164 5031 34133 0.00180 946796 5031 941765 0.04870 784897 3600 781297 0.04040 82283 82283 0.00430 867180 3600 863580 0.04470 1813976 8631 1805345 0.09340 1 1744842 2234064 2338061 -103997 X 1 1 1 1 FAIRBANKS HOSPITAL INC

8102 CLEARVISTA PARKWAY INDIANAPOLIS IN 46256

X LICENSED PRIVATE MENTAL HEALTH INSTITUTION FAIRBANKS HOSPITAL INC 1 1 X X X X X X X X 1 0 1 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 4 LAVERNA LODGE

8102 CLEARVISTA PARKWAY INDIANAPOLIS IN 46256

DRUG & ALCOHOL RESIDENTIAL REHAB 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, L7 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 4: PART III, SECTION A, LINE 2, BAD DEBT EXPENSE METHODOLOGY: THE AMOUNT OF BAD DEBT HAS BEEN PROVIDED FROM THE AUDITED FINANCIAL STATEMENTS. PART III, SECTION A, 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, SECTION A, LINE 4, BAD DEBT EXPENSE FOOTNOTE TO AUDITED FINANCIAL STATEMENTS: 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. ASU 2011-07 REQUIRES HEALTHCARE ENTITIES TO PROVIDE ENHANCED DISCLOSURE ABOUT THEIR POLICIES FOR RECOGNIZING REVENUE AND ASSESSING BAD DEBTS, AS WELL AS QUALITATIVE AND QUANTITATIVE INFORMATION ABOUT CHANGES IN THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS. INFORMATION IS PROVIDED IN THE NOTES TO THE FINANCIAL STATEMENT UNDER THE "PATIENT ACCOUNTS RECEIVABLE AND NET PATIENT SERVICE REVENUE" AND "ALLOWANCE FOR DOUBTFUL ACCOUNTS" SECTIONS. REPRINTED BELOW IS THE PORTION OF THE NOTES RELATING TO BAD DEBT EXPENSE INCLUDED IN "ALLOWANCE FOR DOUBTFUL ACCOUNTS" AUDITED FINANCIAL STATEMENT FOOTNOTE."ALLOWANCE FOR DOUBTFUL ACCOUNTS" - PATIENT ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS BASED ON FAIRBANKS' EVALUATION OF ITS MAJOR PAYOR SOURCES OF REVENUE, THE AGING OF THE ACCOUNTS, HISTORICAL LOSSES, CURRENT ECONOMIC CONDITIONS, AND OTHER FACTORS UNIQUE TO ITS SERVICE AREA AND THE HEALTHCARE INDUSTRY. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THE MAJOR PAYOR SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, FAIRBANKS ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS, IF NECESSARY. FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PAYMENTS, WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL, FAIRBANKS RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES IF NEGOTIATED) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS.DURING 2013, FAIRBANKS' ALLOWANCE FOR DOUBTFUL ACCOUNTS CHANGED FROM APPROXIMATELY $646,000 TO $886,000. FAIRBANKS ALLOWS FOR ACCOUNTS BASED ON AGING OVER AN ESTABLISHED THRESHOLD. AS OF JUNE 30, 2013, THE ALLOWANCE FOR DOUBTFUL ACCOUNTS OF $886,000 WAS COMPRISED OF $447,000 RESERVED FOR SELF-PAY BALANCES AND $439,000 RESERVED FOR THIRD-PARTY PAYOR BALANCES. AS OF JUNE 30, 2012, THE ALLOWANCE FOR DOUBTFUL ACCOUNTS OF $646,000 WAS COMPRISED OF $498,000 RESERVED FOR SELF-PAY BALANCES AND $148,000 RESERVED FOR THIRD-PARTY PAYOR BALANCES. 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, 2013: 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. 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 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 2013. THE REMAINING STRATEGIES OUR 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. CHNA CONDUCTED PART V, SECTION B WITH REGARDS TO PART V, SECTION B, LINE 2 THE MOST RECENT COMMUNITY HEALTH NEEDS ASSESSMENT WAS REIVEWED BY THE BOARD ON JUNE 26, 2013 AND MADE AVAILABLE TO THE PUBLIC THROUGH POSTING ON ITS WEBSITE DURING NOVEMBER 2013. 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, 2013, 3,460 PERSONS WERE SERVED; 58% FROM UNITED WAY OF CENTRAL INDIANA COUNTIES, 20% SURROUNDING COUNTIES, 21% REMAINING INDIANA COUNTIES, AND 1% 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. X X X X X 0 0 0 0 0 0 0 0 0 HELENE CROSS 158262 0 231487 0 0 0 21496 0 13985 0 425230 0 0 0 TIMOTHY KELLY 186898 0 0 0 0 0 0 0 18485 0 205383 0 0 0 DR DENNIS RHYNE 151245 0 0 0 0 0 0 0 3281 0 154526 0 0 0 DR BARBARA DAVIS 146326 0 0 0 0 0 0 0 8356 0 154682 0 0 0 SUPPLEMENTAL INFORMATION PART III MS. HELEN CROSS IS COMPENSATED FROM FAIRBANKS HOSPITAL, INC. FOR HER DUTIES AS PRESIDENT/ CEO OF THE HOSPITAL. A PORTION OF EHR COMPENSATION RECEIVED FROM FAIRBANKS HOSPITAL, INC. IS ALLOCATED TO HOPE ACADEMY FOR DUTIES PROVIDED. FOR FY 13, 4% OF MS. CROSS' HOURS (83 HOURS ANNUALLY) OR SALARIES AND BENEFITS TOTALING $17,009 ARE ALLOCATED TO HOPE ACADEMY. 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 WHICH TOOK PLACE FOR THE 2012 TAX RETURN ON DECEMBER 18, 2013. 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. RELATED ORGANIZATION HOURS FORM 990, PART VII, SECTION A, LINE 1A MS. HELENE CROSS AND MR. MARK MONSON ARE COMPENSATED FROM FAIRBANKS HOSPITAL, INC. FOR THEIR DUTIES AS PRESIDENT/CEO OF THE HOSPITAL. A PORTION OF THEIR COMPENSATION RECEIVED FROM FAIRBANKS HOSPITAL, INC. IS ALLOCATED TO HOPE ACADEMY FOR DUTIES PROVIDED. FOR FY 13, 4% OF MS. CROSS AND MR. MONSON'S HOURS (83 HOURS ANNUALLY) OR SALARIES AND BENEFITS TOTALING $17,009 AND $2,593, RESPECTIVELY, ARE ALLOCATED TO HOPE ACADEMY. MS. RACHELLE GARDNER IS COMPENSATED FROM FAIRBANKS HOSPITAL, INC. FOR FY 13, 30% OF HER HOURS (624 HOURS ANNUALLY) OR SALARIES AND BENEFITS TOTALING $32,327 ARE ALLOCATED TO HOPE ACADEMY. MS. BARBARA ELLIOTT IS COMPENSATED FROM FAIRBANKS HOSPITAL, INC. FOR FY 13, 10% OF HER HOURS (208 HOURS ANNUALLY) OR SALARIES AND BENEFITS TOTALING $14,570 ARE ALLOCATED TO HOPE ACADEMY. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: NET ASSETS TRANSFERRED TO HOPE ACADEMY -278,811. AUDIT OVERSIGHT FORM 990, PART XI, LINE 2C 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 1 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 278811 COST THE RECOVERY HIGH SCHOOL AT FAIRBANKS INC DBA HOPE ACADEMY D 405340 COST THE RECOVERY HIGH SCHOOL AT FAIRBANKS INC DBA HOPE ACADEMY J 144600 COST