2012-06-01T13:51:02-05:00 2011-07-31 EIDE BAILLY LLP 3999 PENNSYLVANIA AVE SUITE 100 DUBUQUE IA 52002 990 2010-08-01 370645239 CARLINVILLE AREA HOSPITAL ASSOCIATION CARL 2178543141 20733 NORTH BROAD STREET CARLINVILLE IL 62626 KENNETH REID 2178543141 2012-05-08 1 CARMEN KRANTZ 5635561790 2012-04-23 2010 2016-02-24 21:20:13Z KENNETH REID 20733 NORTH BROAD STREET CARLINVILLE IL 62626 21404531 0 X WWW.CAHCARE.COM X 1947 IL PROVIDE QUALITY ACUTE AND PREVENTATIVE HEALTH CARE BENEFITS 7 7 202 7 0 0 5169276 1941015 14891049 19257118 53184 -220898 58376 56895 20171885 21034130 250 0 0 0 7201608 7761222 0 0 0 7051117 12147286 14252975 19908508 5918910 1125622 36167440 33277325 24415448 20342066 11751992 12935259 X TO MAINTAIN A PROFESSIONAL MEDICAL COMMUNITY, A PRIMARY CARE HOSPITAL AND OTHER HEALTH CARE SERVICES, IN ORDER TO PROVIDE QUALITY ACUTE AND PREVENTATIVE HEALTH CARE FOR THE BENEFIT OF THOSE PERSONS LIVING IN THE SERVICE AREA. 0 0 16867468 19257118 DURING FISCAL YEAR 2011, WE CARRIED OUT OUR EXEMPT PURPOSE IN THE FOLLOWING WAYS: 1) PROVIDED QUALITY SHORT TERM ACUTE CARE MEDICAL SERVICES TO 573 INPATIENTS, OF WHICH 79% WERE ELIGIBLE FOR MEDICARE. WITHOUT OUR SERVICES THESE ELDERLY PATIENTS WOULD HAVE HAD TO TRAVEL OVER 20 MILES TO RECEIVE SIMILAR SERVICES. 2) PROVIDED QUALITY SHORT TERM SKILLED CARE TO 188 PATIENTS IN OUR SWING BED UNIT, WITH AN AVERAGE LENGTH OF STAY OF 9.0 DAYS. 3) PROVIDED 24 HOUR A DAY EMERGENCY ROOM SERVICES. OUR EMERGENCY ROOM TREATED 6,692 PATIENTS DURING FISCAL YEAR 2011. WE TREAT EVERYONE WHO PRESENTS THEMSELVES TO OUR EMERGENCY ROOM REGARDLESS OF THEIR MEDICAL CONDITION OR ABILITY TO PAY. WE PROVIDED 24 HOUR PHYSICIAN SERVICE SO THE RESIDENCY OF THE CARLINVILLE AREA DO NOT HAVE TO TRAVEL LONG DISTANCES FOR EMERGENCY MEDICAL CARE. 4) IN ADDITION TO THE INPATIENT AND EMERGENCY SERVICES WE PROVIDE, WE ALSO HAD 21,349 VISITS IN OUR OUTPATIENT DEPARTMENTS. THESE SERVICES RANGE FROM PREVENTATIVE CARE ITEMS SUCH AS MAMMOGRAMS AND LAB TESTS TO REHABILITATIVE SERVICES SUCH AS PHYSICAL AND OCCUPATIONAL THERAPY. 5) THE HOSPITAL ALSO HAD 5,812 VISITS TO THEIR SPECIALTY CLINICS. THESE CLINICS BRING SPECIALIST FROM METROPOLITAN AREAS TO CARLINVILLE ON A ROTATING BASIS. THIS PROVIDES ACCESS TO SPECIALTY SERVICES NOT OTHERWISE OFFERED IN THE AREA. THE HOSPITAL MAINTAINS RECORDS TO IDENTIFY AND MONITOR THE LEVEL OF CHARITY CARE IT PROVIDES. THESE RECORDS INCLUDE THE AMOUNT OF CHARGES FOREGONE FOR SERVICES AND SUPPLIES FURNISHED UNDER ITS CHARITY CARE POLICY. THE AMOUNTS OF CHARGES FOREGONE WERE $556,288 FOR THE YEAR ENDED JULY 31, 2011. THE ESTIMATED COSTS OF THE CHARGES FOREGONE, BASED UPON AN OVERALL COST-TO-CHARGE RATIO CALCULATION, FOR THE YEAR ENDED JULY 31, 2011 WERE $299,000.IN ADDITION, THE HOSPITAL PROVIDES SERVICES TO OTHER MEDICALLY INDIGENT PATIENTS UNDER CERTAIN GOVERNMENT-REIMBURSED PUBLIC AID PROGRAMS. SUCH PROGRAMS PAY PROVIDERS AMOUNTS WHICH ARE LESS THAN ESTABLISHED CHARGES FOR THE SERVICES PROVIDED TO THE RECIPIENTS, AND FOR SOME SERVICES THE PAYMENTS ARE LESS THAN THE COST OF RENDERING THE SERVICES PROVIDED.THE HOSPITAL ALSO COMMITS SIGNIFICANT TIME AND RESOURCES TO ENDEAVORS AND CRITICAL SERVICES WHICH MEET OTHERWISE UNFULFILLED COMMUNITY NEEDS. MANY OF THESE ACTIVITIES ARE SPONSORED WITH THE KNOWLEDGE THAT THEY WILL NOT BE SELF-SUPPORTING OR FINANCIALLY VIABLE. 16867468 1 1 0 0 0 0 0 0 1 1 0 0 0 1 1 1 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 35 0 1 202 1 0 0 0 0 0 0 0 0 0 0 X 7 7 1 1 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 IL X BRIAN ENGELKE 2178543851 20733 NORTH BROAD STREET CARLINVILLE IL 62626 X X J RICHARD SCHIEN 1.00 X X 0 0 0 JAMES SALSKE 1.00 X X 0 0 0 RALPH MARCH 1.00 X X 0 0 0 SHIRLEY BOENTE 1.00 X X 0 0 0 PHILIP WILLIAMS 1.00 X X 0 0 0 STEVE GOURLEY 0.50 X 0 0 0 TRACEY SMITH 0.50 X 0 0 0 RICHARD WALDEN 0.50 X 0 0 0 KENNETH REID 40.00 X 0 0 0 GREG WARD 40.00 X 0 0 0 JON ANDERSEN DO 40.00 X 272528 0 16182 CURTIS CRAVENS 40.00 X 190415 0 21155 CAROL BENNING 40.00 X 109109 0 15023 572052 0 52360 5 0 1 0 ILLINOIS EMERGENCY PHYSICIANS 4075 COPPER RIDGE DRIVE TRAVERSE CITY MI 496840793 EMERGENCY ROOM PHYSICIANS 1331449 HEALTHTECH MANAGEMENT SERVICES INC PO BOX 636426 CINCINNATI OH 452636426 MANAGEMENT SERVICES 676122 ALBERICI CONSTRUCTORS 800 PAGE AVENUE ST LOUIS MO 631146106 CONSTRUCTION 279372 CPSI 6600 WALL ST MOBILE AL 36695 INFORMATION TECHNOLOGY SERVICES 175097 PRECISE SPECIALTIES PO BOX 572 HILLSBORO IL 62049 RADIOLOGY SERVICES 123695 6 1876157 39342 25516 1941015 PATIENT SERVICE REVENU 622110 18750681 18750681 CLINIC REVENUE 621110 400419 400419 SUPPORTING REVENUE 900099 106018 106018 19257118 91078 91078 56895 56895 56895 56895 58425 370401 -311976 -311976 -311976 21034130 19257118 0 -164003 6353885 5306139 1047746 186562 155798 30764 765604 639356 126248 455171 374114 81057 680494 680494 56588 56588 58260 58260 2755513 2625934 129579 107188 107188 3017983 2539697 478286 2108 2108 393932 396408 -2476 18714 7007 11707 70728 25429 45299 1563171 1563171 2043145 2043145 165937 1712 164225 BAD DEBT EXPENSE 1178131 1178131 35394 11427 23967 19908508 16867468 3041040 0 4769595 3314708 1922228 2908720 193250 209967 165548 171970 27084616 3061375 28186787 24023241 348714 643031 444510 502155 136808 1503533 36167440 33277325 2001815 1206108 129112 63338 17610145 18941235 4674376 131385 24415448 20342066 X 8551780 12353104 2675702 0 524510 582155 11751992 12935259 36167440 33277325 X 1125622 57645 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 524510 57645 582155 492838 31672 524510 570417 -77579 492838 0.00000 1.00000 0.00000 1 0 602527 602527 20446181 1900725 18545456 4662299 1047562 3614737 1373609 113088 1260521 24023241 EMPLOYEE HEALTH CLAIMS 93091 CAPITALIZED LEASE OBLIGATION 38294 131385 21034130 19908508 1125622 57645 57645 1183267 19317971 0 19317971 1716159 1716159 21034130 19908508 0 19908508 0 19908508 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: $80,000 IS IN THE POSSESSION OF THE ORGANIZATION FOR HOSPICE CARE. $502,155 IS A BENEFICIAL INTEREST IN A TRUST NOT IN THE POSSESSION OF THE ORGANIZATION AND REPRESENTS CONTRIBUTIONS RECEIVED, WHICH ARE PERMANENTLY RESTRICTED. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE HOSPITAL BELIEVES THAT IT HAS APPROPRIATE SUPPORT FOR ANY TAX POSITIONS TAKEN AFFECTING ITS ANNUAL FILING REQUIREMENTS, AND AS SUCH, DOES NOT HAVE ANY UNCERTAIN TAX POSITIONS THAT ARE MATERIAL TO THE FINANCIAL STATEMENTS. THE HOSPITAL WOULD RECOGNIZE FUTURE ACCRUED INTEREST AND PENALTIES RELATED TO UNRECOGNIZED TAX BENEFITS AND LIABILITIES IN INCOME TAX EXPENSE IF SUCH INTEREST AND PENALTIES ARE INCURRED. PART XI, LINE 8 - OTHER ADJUSTMENTS: CHANGE IN BENEFICIAL INTEREST IN PERPETUAL TRUST 57,645. PART XII, LINE 4B - OTHER ADJUSTMENTS: FOUNDATION TRANSFER RECORDED AS CONTRIBUTION ON FORM 990 1,716,159. 1 1 X 1 X 1 X 0 1 1 0 1 1 299000 299000 0.01600 2029574 1307844 721730 0.03850 2328574 1307844 1020730 0.05450 1071 1071 0.00010 448036 176772 271264 0.01450 494 494 0.00000 449601 176772 272829 0.01460 2778175 1484616 1293559 0.06910 1 200 2030 2030 0.00010 1 600 266 266 0.00000 2 14 119 119 0.00000 4 814 2415 2415 0.00010 0 571151 9298 9919323 9821110 98213 X 1 1 1 1 CARLINVILLE AREA HOSPITAL ASSOCIATION

20733 NORTH BROAD STREET CARLINVILLE IL 62626

X X X X NOT REQUIRED 1 1 CAH OUTPATIENT SPECIALTY CLINIC

20733 NORTH BROAD STREET CARLINVILLE IL 62626

SPECIALTY CLINIC PART I, LINE 6A: THE ANNUAL COMMUNITY BENEFIT REPORT IS MAILED TO 15,000 RESIDENTS IN OUR SERVICE AREA. PART I, LINE 7: CHARITY CARE EXPENSE WAS CONVERTED TO COST ON LINE 7A BASED ON AN OVERALL COST-TO-CHARGE RATIO ADDRESSING ALL PATIENT SEGMENTS. UNREIMBURSED MEDICAID ON LINE 7B WAS CALCULATED USING THE COSTING METHODS TO PREPARE THE COST REPORTS. COMMUNITY HEALTH IMPROVEMENT SERVICES, LINE 7E, HEALTH PROFESSIONS EDUCATION, LINE 7F, AND CASH AND IN-KIND CONTRIBUTIONS, LINE 7I ARE REPORTED BASED ON ACTUAL EXPENSE AND REVENUE AMOUNTS RECORDED FROM THE EVENTS IN THE GENERAL LEDGER. THE COST FOR SUBSIDIZED HEALTH SERVICES REPORTED ON LINE 7G WAS DETERMINED USING THE MEDICARE COST REPORT. PART I, L7 COL(F): THE AMOUNT OF BAD DEBT EXPENSE REMOVED FROM TOTAL EXPENSES TO DETERMINE THE PERCENTAGE WAS $1,178,131. PART II: CARLINVILLE AREA HOSPITAL WAS INVOLVED IN SEVERAL COMMUNITY BUILDING ACTIVITIES THIS YEAR. WE PARTICIPATED IN THE MACOUPIN ECONOMIC DEVELOPMENT PARTNERSHIP. WORKED WITH THE LOCAL COLLEGE IN PROVIDING MOCK INTERVIEWS TO HELP LOCAL STUDENTS SHARPEN THEIR INTERVIEW SKILLS AND BETTER THEIR CHANCES OF GETTING QUALITY JOBS. BY WORKING WITH THESE OTHER GROUPS, WE HOPE TO IMPROVE THE OVERALL ECONOMIC CONDITION OF OUR SERVICES AREA. WE BELIEVE THAT THE ECONOMIC CONDITIONS OF A COMMUNITY HAVE A DIRECT EFFECT ON THE HEALTH OF A COMMUNITY. PART III, LINE 4: THE ORGANIZATION'S BAD DEBT EXPENSE WAS CONVERTED TO COST USING THE COST-TO-CHARGE RATIO DERIVED FROM WORKSHEET 2. THE BAD DEBT EXPENSE DOES NOT INCLUDE CHARITY CARE WRITE OFFS. PATIENTS THAT ARE ELIGIBLE FOR CHARITY CARE ARE WRITTEN OFF AS A REDUCTION IN REVENUE. THE BAD DEBT EXPENSE IS ONLY THE UNCOLLECTED PORTION OF THE PATIENT ACCOUNT. ANY DISCOUNTS WOULD BE TREATED AS A REDUCTION IN REVENUE. ALL FORMS OF PAYMENT, INCLUDING SELF-PAY, INSURANCE, CONTRACTUAL ALLOWANCES, AND DISCOUNTS REDUCE THE PATIENT'S ACCOUNT PRIOR TO THE ACCOUNT BEING CLASSIFIED AS BAD DEBT. A PAYMENT RECEIVED ON AN ACCOUNT PREVIOUSLY WRITTEN OFF AS BAD DEBT REDUCES BAD DEBT EXPENSE. THE ESTIMATED AMOUNT OF THE ORGANIZATION'S BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY IS CALCULATED BASED ON AN ESTIMATE OF CHARGES FOREGONE TO GROSS PATIENT CHARGES.FINANCIAL STATEMENT FOOTNOTE: THE CARRYING AMOUNT OF PATIENT RECEIVABLES IS REDUCED BY A VALUATION ALLOWANCE THAT REFLECTS MANAGEMENT'S ESTIMATE OF AMOUNTS THAT WILL NOT BE COLLECTED FROM PATIENTS AND THIRD-PARTY PAYORS. MANAGEMENT REVIEWS PATIENT RECEIVABLES BY PAYOR CLASS AND APPLIES PERCENTAGES TO DETERMINE ESTIMATED AMOUNTS THAT WILL NOT BE COLLECTED FROM THIRD PARTIES UNDER CONTRACTUAL AGREEMENTS AND AMOUNTS THAT WILL NOT BE COLLECTED FROM PATIENTS DUE TO BAD DEBTS. MANAGEMENT CONSIDERS HISTORICAL WRITE OFF AND RECOVERY INFORMATION IN DETERMINING THE ESTIMATED BAD DEBT PROVISION. MANAGEMENT ALSO REVIEWS ACCOUNTS TO DETERMINE IF CLASSIFICATION AS CHARITY CARE IS APPROPRIATE. PART III, LINE 8: BOTH THE TOTAL REVENUE RECEIVED FROM MEDICARE AND THE MEDICARE ALLOWABLE COSTS ARE REPORTED FROM THE MEDICARE COST REPORT. PART III, LINE 9B: CARLINVILLE AREA HOSPITAL ASSOCIATION WILL GIVE THE CHARITY CARE APPLICANT AT LEAST 60 DAYS FROM THE DATE OF SERVICE TO APPLY FOR FINANCIAL ASSISTANCE WITHOUT ANY COLLECTION EFFORTS. IF THE APPLICANT HAS APPLIED FOR HEALTH CARE COVERAGE UNDER MEDICAID, KIDCARE, OR OTHER GOVERNMENT SPONSORED HEALTH CARE PROGRAMS, CARLINVILLE AREA HOSPITAL WILL AWAIT THE APPROVAL OR DENIAL OF THE APPLICATION WITHOUT ADDITIONAL COLLECTION EFFORTS.CARLINVILLE AREA HOSPITAL ASSOCIATION WILL NOT REFER A BILL TO COLLECTION WITHOUT FIRST OFFERING THE PATIENT THE OPPORTUNITY TO REQUEST A REASONABLE PAYMENT PLAN FOR THE AMOUNT PERSONALLY OWED BY THE PATIENT. SUCH AN OPPORTUNITY SHALL BE MADE AVAILABLE FOR THE 30 DAYS FOLLOWING THE DATE OF THE INITIAL BILL. IF THE PATIENT REQUESTS A REASONABLE PAYMENT PLAN, BUT FAILS TO AGREE TO A PLAN WITHIN 30 DAYS OF THE REQUEST THE HOSPITAL MAY PROCEED WITH COLLECTION ACTION AGAINST THE PATIENT.NO COLLECTION EFFORTS WILL BE PURSUED IF THE UNINSURED PATIENT HAS AGREED TO A REASONABLE PAYMENT PLAN AND THE PATIENT KEEPS TO THE AGREEMENT. IF THE PATIENT FAILS TO MAKE THE PAYMENTS AGREED UPON, REGULAR COLLECTION EFFORTS WILL BE PURSUED.CARLINVILLE AREA HOSPITAL ASSOCIATION WILL NOT PURSUE LEGAL ACTION FOR NON-PAYMENT OF A HOSPITAL BILL AGAINST UNINSURED PATIENTS WHO HAVE CLEARLY DEMONSTRATED THAT THEY HAVE NEITHER SUFFICIENT INCOME NOR ASSETS TO MEET THEIR FINANCIAL OBLIGATIONS. PART VI, LINE 2: THE HOSPITAL WORKS WITH PHYSICIANS, THE HEALTH DEPARTMENT, NURSING HOMES AND OTHER HEALTH CARE PROVIDERS IN THE COMMUNITY TO DETERMINE THE HEALTH CARE NEEDS. THE HOSPITAL ALSO FORMED A PARTNERSHIP WITH ILLINOIS EMERGENCY PHYSICIANS, LLP. THE PHYSICIANS OF THE PARTNERSHIP SERVE IN A DUAL ROLE AT CARLINVILLE AREA HOSPITAL. THEY HAVE IMPROVED THE SERVICE IN THE GROWING EMERGENCY DEPARTMENT, AND ACT AS HOSPITALIST PHYSICIANS. THIS MEANS THEY CAN ADMIT AND CARE FOR PATIENTS WHO DO NOT HAVE A PHYSICIAN THAT REGULARLY ADMITS PATIENTS TO THE HOSPITAL. SOME OF THE STAFF PHYSICIANS AT CARLINVILLE AREA HOSPITAL MAY ALSO ELECT TO USE THE PHYSICIANS IN THE PARTNERSHIP TO ASSIST IN MANAGING THE CARE OF THEIR OWN ADMITTED PATIENTS. PART VI, LINE 3: THE FULL CHARITY CARE POLICY IS POSTED ON THE HOSPITAL'S WEB SITE. FINANCIAL ASSISTANCE CONTACT INFORMATION IS PROVIDED ON EACH BILL. A NOTICE ABOUT THE AVAILABILITY OF CHARITY CARE IS POSTED IN THE ADMITTING AREAS, INCLUDING THE ER. THE HOSPITAL ALSO EMPLOYEES A FULL TIME FINANCIAL COUNSELOR TO DISCUSS THE AVAILABILITY OF VARIOUS GOVERNMENT SERVICES AND CHARITY CARE WITH PATIENTS. PART VI, LINE 4: CARLINVILLE AREA HOSPITAL ASSOCIATION IS A 25-BED ACUTE CARE HOSPITAL LOCATED IN CARLINVILLE, ILLINOIS. THE HOSPITAL SERVES THE RESIDENTS OF MACOUPIN COUNTY. CARLINVILLE AREA HOSPITAL IS THE ONLY HOSPITAL WITHIN A 20 MILE RADIUS OF CARLINVILLE ILLINOIS, A SMALL RURAL COMMUNITY IN CENTRAL ILLINOIS. ILLINOIS ROUTE 4 PASSES THROUGH CARLINVILLE. INTERSTATE 55 IS ALSO WITHIN 12 MILES OF THE CITY. THE COMMUNITY IS MOSTLY AGRICULTURAL.CARLINVILLE HAD A POPULATION OF 5,912 IN JULY 2009 WITH AN ESTIMATED MEDIAN HOUSEHOLD INCOME OF $42,489. CARLINVILLE RESIDENTS WITH INCOME BELOW THE POVERTY LEVEL IN 2009 WAS 12.5% AND RESIDENTS WITH INCOME BELOW 50% OF THE POVERTY LEVEL WAS 3.1%. PART VI, LINE 6: CARLINVILLE AREA HOSPITAL ASSOCIATION'S CORE PURPOSE IS "EXCELLENT HEALTHCARE CLOSE TO HOME." THIS IS VERY IMPORTANT TO OUR BOARD AS ALL OF OUR MEMBERS LIVE IN OUR SERVICE AREA AND USE OUR FACILITY. THE HOSPITAL EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN THE COMMUNITY. CARLINVILLE AREA HOSPITAL INVESTS IN IMPROVEMENTS IN THE COMMUNITY AND CONTINUES TO MINIMIZE LONG-TERM DEBT. DURING THIS FISCAL YEAR CARLINVILLE AREA HOSPITAL FINISHED CONSTRUCTION OF NEW HOSPITAL. THE NEW FACILITY REPLACES A STRUCTURE THAT WAS BUILT IN THE 1950S AND WAS NO LONGER MEETING HEALTH SAFETY CODES. THE HOSPITAL ALSO PROVIDES THE FOLLOWING SERVICES THAT WOULD NOT OTHERWISE BE AVAILABLE WITHIN THE HOSPITAL'S SERVICE AREA: TWENTY-FOUR HOUR A DAY EMERGENCY ROOM THAT TREATS ALL PATIENTS REGARDLESS OF ABILITY TO PAY SPECIALTY CLINIC - THE HOSPITAL HAS AN ARRANGEMENT WITH A PHYSICIAN GROUP OUT OF SPRINGFIELD, IL THAT BRINGS SPECIALISTS TO THE CARLINVILLE AREA THAT WOULD NOT OTHERWISE BE AVAILABLE.THROUGHOUT THE YEAR, CARLINVILLE AREA HOSPITAL OFFERED CPR TRAINING TO THE COMMUNITY FOR A SPECIAL RATE OF $12 PER PARTICIPANT.THE HOSPITAL PROVIDED FREE BLOOD PRESSURE CHECKS IN CARLINVILLE AND PALMYRA ON A MONTHLY BASIS.CARLINVILLE AREA HOSPITAL'S IMAGING DEPARTMENT HOSTED A FREE COMMUNITY PRESENTATION IN OBSERVANCE OF NATIONAL BREAST CANCER AWARENESS MONTH IN OCTOBER. EARLY DETECTION, BENEFITS OF DIGITAL MAMMOGRAPHY, AND HOW THE ADVANCED TECHNOLOGY AIDS IN EARLY DETECTION WERE DISCUSSED.APPROXIMATELY 16 CHURCHES THROUGHOUT MACOUPIN COUNTY RECEIVED FIRST AID SUPPLY BAGS FROM CARLINVILLE AREA HOSPITAL. THE BAGS INCLUDED A PILLOW, BLANKET, STETHOSCOPE, BLOOD PRESSURE CUFF, GLOVES, DISPOSABLE WASHCLOTHS, ICE PACKS, POCKET CPR MASK, BAND AIDS, VARIOUS DRESSINGS, PEROXIDE, ALCOHOL WIPES, AND COTTON BALLS. THESE BASIC SUPPLIES WERE PROVIDED TO HELP THE CHURCHES DURING SERVICES OR ACTIVITIES WHEN CHURCH MEMBERS MAY BECOME ILL OR INJURED.CARLINVILLE AREA HOSPITAL PARTICIPATED IN THE ILLINOIS COOPERATIVE WORK STUDY PROGRAM. THE PROGRAM OFFERED OPPORTUNITIES FOR COLLEGE STUDENTS TO GAIN HANDS-ON EXPERIENCE IN THEIR FIELD OF STUDY. THE HOSPITAL ALSO SERVED AS A CLINICAL SITE FOR STUDENTS IN RADIOLOGY FROM SOUTHWESTERN ILLINOIS COLLEGE AND PHARMACY FROM ST. LOUIS COLLEGE OF PHARMACY. REPORTS FILED WITH STATES PART VI, LINE 7 IL X X X X 0 0 0 0 0 0 0 0 0 JON ANDERSEN DO 270000 0 0 0 2528 0 9450 0 7222 0 289200 0 0 0 CURTIS CRAVENS 187836 0 0 0 2579 0 11221 0 10261 0 211897 0 0 0 SUPPLEMENTAL INFORMATION PART III PART I, QUESTION 3: CARLINVILLE AREA HOSPITAL ASSOCIATION DOES NOT PAY COMPENSATION TO THE CEO DIRECTLY. THE CEO IS COMPENSATED BY AN UNRELATED MANAGEMENT COMPANY, HEALTHTECH MANAGEMENT SERVICES, INC. THE HOSPITAL BOARD OF DIRECTORS USES THE PROCESSES DESCRIBED IN PART I, QUESTION 3 TO DETERMINE APPROPRIATE COMPENSATION FOR THE CEO. THE BOARD OF DIRECTORS ALSO APPROVES THE ORGANIZATION'S CONTRACT WITH THE MANAGEMENT COMPANY. FORM 990, PART VI, SECTION A, LINE 1 THE EXECUTIVE COMMITTEE IS COMPOSED OF THE ELECTED OFFICERS OF THE BOARD AND INCLUDES: THE CHAIRMAN, VICE-CHAIRMAN, PRESIDENT, SECRETARY AND TREASURER OF THE ASSOCIATION. THE EXECUTIVE COMMITTEE HAS POWER AND AUTHORITY TO MANAGE AND CONTROL THE BUSINESS AND AFFAIRS OF THE ASSOCIATION AS THE BOARD OF DIRECTORS DETERMINES. HOWEVER, IN NO EVENT SHOULD THE EXECUTIVE COMMITTEE EXERCISE THOSE POWERS PROHIBITED BY ILLINOIS LAW WHICH INCLUDE AMONG OTHERS: TO AMEND THE ASSOCIATION'S ARTICLES OF INCORPORATION OR BYLAWS; TO SELL, TRANSFER OR OTHERWISE DISPOSE OF SUBSTANTIALLY ALL OF THE ASSOCIATION'S ASSETS; OR TO ADOPT ARTICLES OF MERGER OR CONSOLIDATION. FORM 990, PART VI, SECTION A, LINE 2 J. RICHARD SCHIEN, CHAIRMAN, AND RICHARD WALDEN, BOARD MEMBER HAVE A BUSINESS RELATIONSHIP. JAMES SALSKE, VICE CHAIRMAN, AND RICHARD WALDEN, BOARD MEMBER HAVE A BUSINESS RELATIONSHIP. FORM 990, PART VI, SECTION A, LINE 3 THE ORGANIZATION'S CEO AND CFO ARE EMPLOYEES OF HEALTHTECH MANAGEMENT SERVICES, INC., AN UNRELATED MANAGEMENT COMPANY. FORM 990, PART VI, SECTION A, LINE 6 THE ORGANIZATION'S SOLE MEMBER IS MIDDLE MACOUPIN HEALTH CARE SYSTEMS. FORM 990, PART VI, SECTION A, LINE 7A THE MEMBER HAS THE EXCLUSIVE RIGHT AND POWER TO DESIGNATE THREE OF ITS DIRECTORS TO SERVE AS A MEMBER OF THE BOARD OF DIRECTORS, AND BY RESOLUTION TO APPOINT ALL SUCH DIRECTORS OR TO REMOVE THEM FROM THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 7B THE MEMBER HAS THE EXCLUSIVE RIGHT AND POWER TO APPROVE OR REJECT THE FOLLOWING ACTIONS PRIOR TO THE BOARD OF DIRECTORS TAKING ANY ACTION: 1. THE ANNUAL OPERATING BUDGET, CAPITAL BUDGET, LONG-RANGE PLAN AND ANY ACTION WHICH WILL RESULT IN A SUBSTANTIAL CHANGE IN THE EXPENDITURES OR REVENUE FORECAST; 2. THE UNDERTAKING OF OR SUBSTANTIVE AMENDMENTS TO A CONTRACTUAL OBLIGATION IN EXCESS OF $50,000, OR THE GUARANTEEING OF ANY OBLIGATION IN EXCESS OF $50,000; 3. THE PURCHASE, LEASE, TRANSFER, MORTGAGE OR SALE OF ANY ASSET OR PROPERTY WITH A VALUE IN EXCESS OF $50,000, EXCEPT WITH RESPECT TO TRANSACTIONS SPECIFIED AND PREVIOUSLY APPROVED WITHIN THE CAPITAL BUDGET; 4. ANY PLAN OF CONSTRUCTION OR REMODELING INVOLVING AN EXPENDITURE IN EXCESS OF $50,000, EXCEPT WITH RESPECT TO TRANSACTIONS SPECIFIED AND PREVIOUSLY APPROVED WITHIN THE CAPITAL BUDGET; 5. ANY BORROWING; 6. ANY APPLICATION FOR A GOVERNMENT GRANT; 7. ANY GENERAL PLAN FOR THE SOLICITATION OF CHARITABLE CONTRIBUTIONS OR THE SOLICITATION OR ACCEPTANCE AS A GIFT OF ANY REAL PROPERTY OR ANY INTEREST; 8. ANY PROPOSAL TO ADOPT ARTICLES OF DISSOLUTION, MERGER, OR CONSOLIDATION; 9. ANY SELECTION, REMOVAL OR CHANGE IN THE COMPENSATION OR OTHER TERMS OF EMPLOYMENT OF THE OPERATING OFFICERS; 10. ANY SUBSTANTIAL CHANGE IN EMPLOYEE FRINGE BENEFITS OR PERSONNEL POLICIES; AND 11. ANY OTHER MATTERS AS MAY BE REQUIRED BY LAW TO BE SUBMITTED TO THE MEMBER OR AS TO WHICH THE MEMBER DETERMINES, BY RESOLUTION, THAT SUBMISSION IS ADVISABLE. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 IS DISTRIBUTED TO THE GOVERNING BODY BEFORE IT IS FILED. THE CEO, CFO AND DIRECTOR OF FINANCE REVIEW THE FORM 990. FORM 990, PART VI, SECTION B, LINE 12C ANY DUALITY OF INTEREST OR POSSIBLE CONFLICT OF INTEREST ON THE PART OF ANY BOARD MEMBER SHOULD BE DISCLOSED TO THE OTHER MEMBERS OF THE BOARD AND MADE A MATTER OF RECORD THROUGH AN ANNUAL PROCEDURE AND ALSO WHEN THE INTEREST BECOMES A MATTER OF BOARD ACTION. ANY BOARD MEMBER HAVING A DUALITY OF INTEREST OR POSSIBLE CONFLICT OF INTEREST ON ANY MATTER SHOULD NOT VOTE OR USE HIS OR HER PERSONAL INFLUENCE ON THE MATTER. THE MINUTES OF THE MEETING MUST REFLECT THE DISCLOSURE, THE ABSTENTION FROM VOTING, AND THE QUORUM SITUATION. ANY NEW MEMBER OF THE BOARD WILL BE ADVISED OF THIS POLICY UPON ENTERING ON THE DUTIES OF OFFICE. THE GOVERNING BOARD, CEO, AND CFO COMPLETE AND SIGN THE CONFLICT OF INTEREST FORM YEARLY. THE FORMS ARE REVIEWED BY THE CEO OF THE ORGANIZATION AND IF A POTENTIAL CONFLICT IS IDENTIFIED THE CEO FOLLOWS UP. FORM 990, PART VI, SECTION B, LINE 15 THE CEO AND CFO ARE COMPENSATED THROUGH HEALTHTECH MANAGEMENT SERVICES, INC., AN UNRELATED MANAGEMENT COMPANY. THEY ARE CONSIDERED COMMON LAW EMPLOYEES OF HEALTHTECH MANAGEMENT SERVICES, INC. HEALTHTECH MANAGEMENT SERVICES, INC. GIVES THE BOARD OF DIRECTORS A RECOMMENDED SALARY RANGE FOR THE CEO AND CFO AND THE BOARD SETS THE COMPENSATION WITHIN THIS RANGE AFTER REVIEW OF PERFORMANCE EVALUATIONS AND COMPARABILITY DATA. THE PROCESS IS DOCUMENTED AND IS COMPLETED ON AN ANNUAL BASIS. THE LAST COMPLETION WAS IN FY 2011. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE NOT AVAILABLE TO THE PUBLIC. FINANCIAL INFORMATION IS AVAILABLE THROUGH THE PUBLIC DISCLOSURE COPY OF THE 990. FORM 990, PART VII, SECTION A: THE FOLLOWING INDIVIDUALS DEVOTED TIME PROVIDING SERVICES TO THE FOLLOWING RELATED ORGANIZATIONS. CARLINVILLE AREA HOSPITAL FOUNDATION KENNETH REID, CEO 1 HOUR PER WEEK GREG WARD, CFO 1 HOUR PER WEEK RICHARD WALDEN .5 HOURS PER WEEK RALPH MARCH .3 HOURS PER WEEK MIDDLE MACOUPIN HEALTHCARE SYSTEMS KENNETH REID .25 HOURS PER WEEK GREG WARD .25 HOURS PER WEEK RICHARD WALDEN .25 HOURS PER WEEK J. RICHARD SCHIEN .25 HOURS PER WEEK JAMES SALSKE .25 HOURS PER WEEK SHIRLEY BOENTE .25 HOURS PER WEEK PHILIP WILLIAMS .25 HOURS PER WEEK RALPH MARCH .25 HOURS PER WEEK CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: CHANGE IN BENEFICIAL INTEREST IN PERPETUAL TRUST 57,645. TOTAL TO FORM 990, PART XI, LINE 5: 57,645. CARLINVILLE AREA HOSPITAL FOUNDATION 20733 NORTH BROAD STREET CARLINVILLE IL 62626 371193348 SUPPORT CARLINVILLE AREA HOSPITAL ASSOCIATION IL 501(C)(3) LINE 11A, I MIDDLE MACOUPIN HEALTHCARE SYSTEMS 0 MIDDLE MACOUPIN HEALTHCARE SYSTEMS 20733 NORTH BROAD STREET CARLINVILLE IL 62626 371193396 PROVIDE SUPPORT AND BENEFIT CARLINVILLE AREA HOSPITAL ASSOCIATION IL 501(C)(3) LINE 11A, I N/A 0 0 0 1 0 0 0 0 0 0 0 0 1 1 1 0 0 0 0