2024-05-07T10:49:56-05:00 2023-06-30 351178661 BLUE & CO LLC 2650 EASTPOINT PKWY SUITE 300 LOUISVILLE KY 40223 990 2022-07-01 370661202 FAIRFIELD MEMORIAL HOSPITAL ASSOCIATION FAIR 6168422611 303 NW 11TH STREET FAIRFIELD IL 62837 KRISTIN BOLDT CFO 6168422611 2024-05-07 1 KRISTIN BOLDT 0 EMILIE M KNIERIEM CPA P01330194 5029923500 2024-05-06 2 AAL1 IAL1 2022 2023-04-26 12:10:37Z KRISTIN BOLDT 303 NW 11TH STREET FAIRFIELD IL 62837 52044333 0 X FAIRFIELDMEMORIAL.ORG X 1948 IL THE MISSION OF FAIRFIELD MEMORIAL HOSPITAL IS TO MAINTAIN AND IMPROVE THE HEALTH OF THE COMMUNITIES WE SERVE. 9 9 477 34 0 0 3673911 305017 43986120 49686790 52981 23098 583645 1927733 48296657 51942638 56887 48483 0 0 22750678 28032212 0 0 0 20298782 24011774 43106347 52092469 5190310 -149831 57270866 60681272 28249079 33464736 29021787 27216536 X THE MISSION OF FAIRFIELD MEMORIAL HOSPITAL IS TO MAINTAIN AND IMPROVE THE HEALTH OF THE COMMUNITIES WE SERVE. 0 0 45943384 48483 51420189 AS A NOT-FOR-PROFIT COMMUNITY HOSPITAL, FAIRFIELD MEMORIAL IS A CHARITABLE ORGANIZATION THAT EXISTS TO ADVANCE THE HEALTH OF THE RESIDENTS OF WAYNE COUNTY AND SURROUNDING COMMUNITIES. FAIRFIELD MEMORIAL HOSPITAL OPERATES A RURAL HEALTHCARE FACILITY WITH 25 ACUTE CARE BEDS AND 30 SKILLED CARE BEDS. IN AUGUST 2008, THE HOSPITAL OPENED AN OUTPATIENT PHYSICIAN CLINIC. FAIRFIELD MEMORIAL HOSPITAL PROVIDES QUALITY MEDICAL HEALTHCARE TO ALL PERSONS WITHOUT REGARD TO AND DOES NOT DISCRIMINATE ON THE BASIS OF RACE, COLOR, RELIGIONS (CREED), GENDER, GENDER SEX EXPRESSION, AGE, NATIONAL ORIGIN (ANCESTRY), PHYSICAL OR MENTAL DISABILITY, MARITAL STATUS, GENDER IDENTITY, SEXUAL ORIENTATION, SOCIAL ECONOMIC STATUS, ETHNICITY, CULTURE, LANGUAGE, MILITARY STATUS, OR ABILITY TO PAY. ALTHOUGH REIMBURSEMENT FOR SERVICES RENDERED IS CRITICAL TO THE OPERATION AND STABILITY OF FAIRFIELD MEMORIAL HOSPITAL, IT IS RECOGNIZED THAT NOT ALL INDIVIDUALS POSSESS THE ABILITY TO PURCHASE ESSENTIAL MEDICAL SERVICES. THEREFORE, IN KEEPING WITH THIS CORPORATION'S COMMITMENT TO SERVE ALL MEMBERS OF THE COMMUNITIES WE SERVE. THE COMMUNITY, FREE CARE AND/OR SUBSIDIZED CARE, CARE PROVIDED TO PERSONS COVERED BY GOVERNMENTAL PROGRAMS AT BELOW COST, AND HEALTH ACTIVITIES AND PROGRAMS TO SUPPORT THE COMMUNITY WILL BE CONSIDERED WHERE THE NEED AND/OR INDIVIDUALS INABILITY TO PAY COEXISTS. THE COMMUNITY BENEFITS CAN BE MEASURED IN MANY WAYS INCLUDING: DIRECT PATIENT CARE, SCREENINGS, EDUCATION, FUNDRAISING, AND COMMUNITY SERVICE EFFORTS OF OUR COLLEAGUES. THE HOSPITAL PROVIDES CARE TO PERSONS COVERED BY GOVERNMENTAL PROGRAMS, PROVIDING SERVICES TO BOTH MEDICARE AND MEDICAID PATIENTS. CHARITY CARE IS ALSO PROVIDED THROUGH THE HOSPITAL'S INTERNAL POLICY. 45943384 1 1 0 1 0 0 0 0 0 0 1 0 0 0 0 1 1 0 0 0 0 0 0 0 1 0 1 1 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 1 24 0 1 477 1 0 0 0 0 0 0 0 0 0 0 0 0 X 9 9 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 IL X KRISTIN BOLDT 6188478260 303 NW 11TH FAIRFIELD IL 62837 PATRICK MOLT MD PRESIDENT/CMO 20.00 X X 104670 0 0 JOEY HUNGERFORD VICE PRESIDENT 1.75 X X 0 0 0 ANITA POND SECRETARY/TREASURER 1.75 X X 0 0 0 MICHAEL COPELAND DIRECTOR 1.25 X 0 0 0 DONNA MASTERSON DIRECTOR 1.25 X 0 0 0 D JAMIE POLLARD DIRECTOR 1.25 X 0 0 0 MATTHEW SENG DIRECTOR 1.25 X 0 0 0 DOUG WILSON DIRECTOR 1.25 X 0 0 0 TOBY HUCKER DIRECTOR (END 07/22) 1.25 X 0 0 0 JOSH SCOTT DIRECTOR (BEG 01/23) 1.25 X 0 0 0 KATHERINE BUNTING CEO 40.00 X 353526 0 15856 DANA TAYLOR COO 50.00 X 139234 0 9039 HAZEL VEST CNO (END 07/22) 40.00 X 93907 0 11465 AMY MARSH GRAY CFO 40.00 X 134151 0 3537 RACHEL EWING CNO (BEG 09/22) 50.00 X 110733 0 7605 KORY BLANK ORTHOPEDIC SURGEON 40.00 X 731776 0 3167 ALEXIS KING CRNA 40.00 X 342472 0 9373 MARLA LAFIKES PHYSICIAN 40.00 X 307287 0 17377 CHRISTOPHER BALLARD PHYSICIAN 40.00 X 359333 0 15483 LOUIS REMYNSE UROLOGIST 40.00 X 440887 0 5690 3117976 0 98592 22 0 1 0 DR RODNEY BEELER 2142 KETTLE HILL CT EVANSVILLE IN 47725 ER PHYSICIAN 459553 DR DOUGLAS FRANKEL 407 S MARKET STREET MARION IL 62959 ER PHYSICIAN 440822 DR JASIRI KENNEDY 11817 BORDEN ROAD HERALD CA 956389707 ER PHYSICIAN 431912 DR SCOTT ROUSTIO 8422 BRAESWOOD ESTATES DRIVE OFALLON IL 62269 ER PHYSICIAN 325032 DR MARK ROTICH 1401 DANIELLE CT MARION IL 62959 ER PHYSICIAN 314145 6 7200 36111 261706 305017 NET PATIENT REVENUE 621999 44999138 44999138 CLINIC REVENUE 621399 4135379 4135379 HOME HEALTH REVENUE 621399 540033 540033 MEDICAL RECORDS FEE 900099 12240 12240 49686790 22514 22514 433503 92373 341130 341130 341130 584 0 584 584 584 5100 7200 9322 -4222 -4222 CONTRACT SERVICES 900099 1160038 1160038 CAFETERIA & CATERING 722310 241797 232231 9566 188990 188990 1590825 51942638 51420189 0 217432 X 48483 48483 733556 656074 77482 215641 192864 22777 21738584 19442417 2296167 176701 158036 18665 3801511 3399971 401540 1366219 1221911 144308 116647 116647 102442 102442 6530442 5071387 1459055 253214 80890 172324 515084 480964 34120 915247 915247 162318 51852 110466 489517 345290 144227 2645557 2645557 457169 457169 MEDICAL SUPPLIES AND DR 8936497 8936497 MEDICAID ASSESSMENT TAX 1091292 1091292 REPAIRS AND MAINTENANCE 972917 707328 265589 FOOD 344248 344248 479183 153076 326107 52092469 45943384 6149085 0 2781281 866452 3682279 1036229 8157768 12482110 2563487 1315062 1155014 1214850 428199 578038 75822694 32672641 38443370 43150053 1761 1761 57707 36717 57270866 60681272 5831816 7038852 559604 1098906 21857659 25326978 28249079 33464736 X 28819241 27013990 202546 202546 29021787 27216536 57270866 60681272 -149831 -1655420 0 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 14637 14637 0 PART II-B, LINE 1: FMH PAID FOR IHA AND AHA MEMBERSHIP DUES IN FYE 2023. THE PORTION OF MEMBERSHIP DUES ATTRIBUTABLE TOWARDS LOBBYING EXPENDITURES WERE 43.5% AND 27.29% RESPECTIVELY. 474428 474428 43386012 17596920 25789092 1318626 721321 597305 26257071 14354400 11902671 4386557 4386557 43150053 X 51942638 0 51942638 0 51942638 52092469 0 52092469 0 52092469 PART X, LINE 2: THE HOSPITAL HAS BEEN RECOGNIZED AS EXEMPT FROM INCOME TAXES UNDER SECTION 501 OF THE INTERNAL REVENUE CODE AND A SIMILAR PROVISION OF STATE LAW. HOWEVER, THE HOSPITAL IS SUBJECT TO FEDERAL INCOME TAX ON ANY UNRELATD BUSINESS TAXABLE INCOME. THE HOSPITAL FILES TAX RETURNS IN THE U.S. FEDERAL JURISDICTION. MURDER MYSTERY 12300 7200 5100 50 1310 4141 3821 12300 7200 5100 50 1310 4141 3821 9322 -4222 1 1 X 1 X 1 X 1 1 0 1 1 905825 905825 0.01740 10237713 5467680 4770033 0.09160 11143538 5467680 5675858 0.10900 385033 385033 0.00740 385033 385033 0.00740 11528571 5467680 6060891 0.11640 1 4616153 257238 5974275 12972612 -6998337 X 1 1 1 1 FAIRFIELD MEMORIAL HOSPITAL 303 NW 11TH STREET FAIRFIELD IL 62837 WWW.FAIRFIELDMEMORIAL.ORG 0000679 X X X X FAIRFIELD MEMORIAL HOSPITAL 1 0 0 1 X X X X X X X X X 22 1 0 0 1 X WWW.FAIRFIELDMEMORIAL.ORG/RESOURCES/COMMUNITY-REPORTS/ X 1 22 1 WWW.FAIRFIELDMEMORIAL.ORG/RESOURCES/COMMUNITY-REPORTS/ 0 1 X 200.000000000000 300.000000000000 X X 1 1 X X X 1 X WWW.FAIRFIELDMEMORIAL.ORG/ASSISTANCE/FINANCIAL-ASSISTANCE/ X WWW.FAIRFIELDMEMORIAL.ORG/ASSISTANCE/FINANCIAL-ASSISTANCE/ X WWW.FAIRFIELDMEMORIAL.ORG/ASSISTANCE/FINANCIAL-ASSISTANCE/ X X X X X X 1 X 0 X X X 1 X 0 0 FAIRFIELD MEMORIAL HOSPITAL PART V, SECTION B, LINE 5: THE HOSPITAL TOOK INTO ACCOUNT INPUT FROM PERSONS WHO REPRESENT THE BROAD INTERESTS OF THE COMMUNITY SERVED BY THE HOSPITAL. THESE INCLUDED THOSE WITH SPECIAL KNOWLEDGE OF, OR EXPERTISE IN PUBLIC HEALTH (LOCAL, REGIONAL, STATE AND/OR TRIBAL), MEMBERS OF THE MEDICALLY UNDERSERVED, LOW-INCOME, AND MINORITY POPULATIONS SERVED BY THE HOSPITAL AND/OR INDIVIDUALS OR ORGANIZATIONS REPRESENTING THE INTERESTS OF SUCH POPULATIONS. THE MEDICALLY UNDERSERVED ARE MEMBERS OF A POPULATION WHO EXPERIENCE HEALTH DISPARITIES, ARE AT RISK OF NOT RECEIVING ADEQUATE MEDICAL CARE AS A RESULT OF BEING UNINSURED OR UNDERINSURED, AND/OR EXPERIENCING BARRIERS TO HEALTHCARE DUE TO GEOGRAPHIC, LANGUAGE, FINANCIAL, AND OTHER BARRIERS. MEMBERS OF THE CHNA STEERING COMMITTEE, ALONG WITH THOSE WHO PARTICIPATED IN FOCUS GROUPS, AND THE NEEDS INDENTIFICATION AND PRIORITIZATION PROCESS, WERE CHOSEN BASED ON THEIR UNIQUE EXPERTISE AND EXPERIENCE, INFORMED PERSPECTIVE, AND INVOLVEMENT WITH THE COMMUNITY. THE CHNA STEERING COMMITTEE MEMBERS INCLUDED:-A GROCERY STORE MANAGER-A PUBLIC TRANSPORTATION MANAGER-A SCHOOL ADMINISTRATOR-A PHYSICIAN/SURGEON-A COUNTY HEALTH DEPARTMENT ADMINISTRATOR-A PHARMACIST FROM THE COMMUNITY-A FAMILY PRACTICE PHYSICIAN-A BEHAVIORAL THERAPIST FAIRFIELD MEMORIAL HOSPITAL PART V, SECTION B, LINE 11: TWO FOCUS GROUPS MET TO DISCUSS THE STATE OF OVERALL HEALTH AND WELLNESS IN THE FAIRFIELD MEMORIAL HOSPITAL SERVICE AREA AND TO IDENTIFY HEALTH CONCERNS AND NEEDS IN THE DELIVERY OF HEALTHCARE AND HEALTH SERVICES IN ORDER TO IMPROVE WELLNESS AND REDUCE CHRONIC ILLNESS FOR ALL RESIDENTS. THE FOCUS GROUPS INCLUDED REPRESENTATION OF HEALTHCARE PROVIDERS, COMMUNITY LEADERS, COMMUNITY SERVICES PROVIDERS, SCHOOLS, A COMMUNITY COLLEGE, FAITH-BASED ORGANIZATIONS, LOCAL ELECTED OFFICIALS, PUBLIC HEALTH AND OTHERS. SOME MEMBERS OF THESE GROUPS PROVIDED SERVICES TO UNDERSERVED AND UNSERVED PERSONS AS ALL OR PART OF THEIR ROLES. 1. THE GROUP FIRST IDENTIFIED AND PRIORITIZED AVAILABILITY OF MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES, INCLUDING:- IMPROVED ACCESS FOR TRANSPORTATION (LOCAL AND DISTANT) FOR PERSONS WITH MENTAL HEALTH AND SUBSTANCE USE DISORDERS- ACCESS TO A LOCAL PSYCHIATRIST- IMPROVED ACCESS TO SOCIAL WORKERS, LICENSED COUNSELORS, AND CERTIFIED PEER COUNSELORS- INCREASED EDUCATION FOR PARENTS AND YOUTH ABOUT MENTAL HEALTH AND SUBSTANCE USE ISSUES2. THE GROUP NEXT PRIORITIZED TRANSPORTATION- STRENGTHEN LOCAL AMBULANCE SERVICES- IMPROVED ACCESS TO RELIABLE, FLEXIBLE TRANSPORTATION TO AND FROM MEDICAL APPOINTMENTS AND CARE3. THE THIRD PRIORITIZED NEED WAS IMPROVED ACCESS TO PHYSICAL THERAPY AND LOCAL OPPORTUNITIES FOR RECREATION AND EDUCATION.- IMPROVE ACCESS TO PHYSICAL THERAPY SERVICES AT FAIRFIELD MEMORIAL HOSPITAL- IMPROVED COMMUNITY ACCESS TO OPPORTUNITIES FOR RECREATION AND EXERCISE FOR ALL AGES IN ALL SEASONS.THE GROUP ADDRESSED THE NEEDS WITH THE FOLLOWING STRATEGIES:- FAIRFIELD MEMORIAL HOSPITAL WILL EXPLORE PARTNERSHIPS TO DEVELOP ADDITIONAL MENTAL HEALTH AND SUBSTANCE USE RESOURCES.- FAIRFIELD MEMORIAL HOSPITAL WILL EXPLORE THE POTENTIAL TO RECRUIT A LOCAL PSYCHIATRIST.- FAIRFIELD MEMORIAL HOSPITAL WILL EXPLORE RECRUITMENT OF SOCIAL WORKERS, LICENSED CLINICAL COUNSELORS, AND CERTIFIED PEER COUNSELORS.- FAIRFIELD MEMORIAL HOSPITAL WILL COLLABORATE WITH LOCAL AGENCIES AND PROVIDERS AS APPROPRIATE TO ADDRESS UNMET MENTAL HEALTH AND SUBSTANCE USE SERVICES AND EDUCATION NEEDS, INCLUDING TRANSPORTATION.- FAIRFIELD MEMORIAL HOSPITAL WILL EXPLORE OPPORTUNITIES FOR MENTAL HEALTH FIRST AID TRAINING FOR ADULTS AND ADULTS INVOLVED WITH YOUTH AND OTHER APPROPRIATE COMMUNITY OUTREACH PROGRAMS.- FAIRFIELD MEMORIAL HOSPITAL WILL EXPLORE PROVIDING EDUCATION TO LOCAL AMBULANCE SERVICES ON FINANCIAL MANAGEMENT.- FAIRFIELD MEMORIAL HOSPITAL WILL EXPLORE COLLABORATION WITH LOCAL AMBULANCE SERVICES, AS MAY BE REASONABLE AND APPROPRIATE, TO IMPROVE OPERATIONS AND PROVIDE EDUCATION.- FAIRFIELD MEMORIAL HOSPITAL WILL EXPLORE COLLABORATION WITH RIDES MASS TRANSIT TO ADDRESS TRANSPORTATION OPPORTUNITIES.- FAIRFIELD MEMORIAL HOSPITAL WILL EXPLORE OPPORTUNITIES FOR EXPANDING THERAPY SERVICES.- FAIRFIELD MEMORIAL HOSPITAL WILL EXPLORE WITH COMMUNITY PARTNERS THE NEED AND OPERATIONAL FEASIBILITY OF AN INDOOR FACILITY FOR RECREATION, EXERCISE, AND EDUCATION LOCATED AT FMH. 1 1 - HORIZON HEALTHCARE 213 NW 10TH STREET STE A FAIRFIELD IL 62837 OUTPATIENT PHYSICIAN CLINIC PART I, LINE 7: THE FAIRFIELD MEMORIAL HOSPITAL ASSOCIATION USED A COST TO CHARGE RATIO AS CALCULATED FROM WORKSHEET 2, RATIO OF PATIENT CARE COST-TO-CHARGES, INCLUDED IN THE SCHEDULE H INSTRUCTIONS TO DETERMINE THE AMOUNTS ON LINE 7 OF PART I OF SCHEDULE H. PART III, LINE 2: FAIRFIELD MEMORIAL HOSPITAL ASSOCIATION CALCULATED BAD DEBT EXPENSE AT COST USING THE COST TO CHARGE RATIO INCLUDED IN THE SCHEDULE H INSTRUCTIONS. PATIENT ACCOUNTS ARE WRITTEN OFF TO BAD DEBT ONLY AFTER ALL COLLECTION PROCEDURES HAVE BEEN EXHAUSTED AS OUTLINED IN SCHEDULE H, PART III LINE 9B. PATIENT ACCOUNTS ARE WRITTEN OFF TO BAD DEBT AFTER ALL DISCOUNTS AND PAYMENTS HAVE BEEN APPLIED. PART III, LINE 3: BASED ON THE HOSPITAL'S EXPERIENCE WITH ALL ITS PATIENTS, THEY ESTIMATE THAT IT IS LIKELY THAT UP TO ONE FOURTH OF THE PATIENT ACCOUNTS WRITTEN OFF TO BAD DEBTS MAY QUALIFY FOR CHARITY CARE OR OTHER ASSISTANCE BUT CHOSE NOT TO APPLY. THEREFORE, 25% OF THE BAD DEBT EXPENSE WAS INCLUDED ON PART III, LINE 3 AT COST. PART III, LINE 4: PATIENT ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS. IN EVALUATING THE COLLECTABILITY OF ACCOUNTS RECEIVABLE, THE HOSPITAL ANALYZES ITS HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYER SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR UNCOLLECTIBLE ACCOUNTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYER 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, THE HOSPITAL ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR UNCOLLECTIBLE ACCOUNTS, IF NECESSARY (FOR EXAMPLE, FOR EXPECTED UNCOLLECTIBLE DEDUCTIBLES AND COPAYMENTS ON ACCOUNTS FOR WHICH THE THIRD-PARTY PAYER HAS NOT YET PAID, OR FOR PAYERS WHO ARE KNOWN TO BE HAVING FINANCIAL DIFFICULTIES THAT MAKE THE REALIZATION OF AMOUNTS DUE UNLIKELY). FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (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), THE HOSPITAL RECORDS A SIGNIFICANT PROVISION FOR UNCOLLECTIBLE ACCOUNTS 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 OR PROVIDED BY POLICY) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. PART III, LINE 8: UNPAID COST OF MEDICARE REPRESENTS THE COST (DETERMINED USING THE OVERALL COST TO CHARGE RATIO) OF PROVIDING SERVICES TO PRIMARILY ELDERLY BENEFICIARIES OF THE MEDICARE PROGRAM, IN EXCESS OF PAYMENTS FOR THOSE SERVICES. IRS REVENUE RULING 69-545, WHICH ESTABLISHED THE COMMUNITY BENEFIT STANDARD FOR NONPROFIT HOSPITALS, STATES THAT IF A HOSPITAL SERVES PATIENTS WITH GOVERNMENT HEALTH BENEFITS, INCLUDING MEDICARE, THEN THIS IS AN INDICATION THAT THE HOSPITAL OPERATES TO PROMOTE THE HEALTH OF THE COMMUNITY. THIS IMPLIES THAT TREATING MEDICARE PATIENTS IS A COMMUNITY BENEFIT. THE FYE2023 COST REPORT WAS USED TO CALCULATE THE MEDICARE SHORTFALL. PART III, LINE 9B: FAIRFIELD MEMORIAL HOSPITAL APPLIES ITS COLLECTION PRACTICES EQUALLY TO ALL PATIENTS, BOTH CHARITY CARE ELIGIBLE AND NON CHARITY CARE ELIGIBLE. THE PROCEDURE FOR COLLECTION ON PATIENT ACCOUNTS IS AS FOLLOWS: SELF-PAY ACCOUNTS AND ACCOUNTS WITH BALANCES AFTER INSURANCE ARE SENT A LETTER REQUESTING PAYMENT.IF NO RESPONSE IS RECEIVED WITHIN 35 DAYS, THE ACCOUNT IS TRANSFERRED TO EARLY-OUT DEPARTMENT FOR A FOLLOW UP STATEMENT/PHONE CALL TO THE PATIENT. THE HOSPITAL OFFERS PATIENTS SEVERAL PAYMENT ALTERNATIVES, INCLUDING CASH/CHECK FOR THE FULL AMOUNT, CREDIT CARD, SHORT TERM MONTHLY INSTALLMENTS BASED ON OUTSTANDING BALANCE. SPECIAL PAYMENT ARRANGEMENTS CAN BE MADE UPON REQUEST AND COMPLETION OF A CREDIT APPLICATION WHICH WILL BE VERIFIED AND APPROVED BY THE BUSINESS OFFICE DIRECTOR. IF PAYMENT OR SATISFACTORY PAYMENT ARRANGEMENTS AS OUTLINED ABOVE ARE NOT MADE, THE ACCOUNT WILL PROCEED THROUGH A COLLECTION PROCESS AS FOLLOWS:DAY 1 - 1ST NOTICEDAY 7-14 - FIRST PHONE CALL IS MADE; AT LEAST ONE PHONE CALL OR NOTICE PER WEEK FOR THE REMAINDER OF THE EARLY OUT 90 DAYS DAY 75 - DEMAND NOTICE DAY 90 - ACCOUNT IS SENT TO COLLECTIONS. ANY ACCOUNT THAT IS SENT TO COLLECTIONS MAY BE TURNED OVER TO AN ATTORNEY, AND ADDITIONAL COSTS ASSOCIATED WITH COLLECTIONS WILL BE ADDED TO THE ACCOUNT. PART VI, LINE 2: THE DETERMINATION OF CURRENT AND FUTURE HEALTHCARE NEEDS OF THE COMMUNITY OR COMMUNITIES SERVED BY FAIRFIELD MEMORIAL HOSPITAL IS BASED ON ALL OR A COMBINATION OF THE FOLLOWING FACTORS: EXISTENCE OR NON EXISTENCE OF SERVICES, OPPORTUNITY, SUPPLY, DEMONSTRATED NEED, "VOICE OF THE CUSTOMER," COLLABORATIVE EFFORTS WITH OUTSIDE ENTITIES, COMMUNITY BASED NEEDS ASSESSMENT, GOVERNMENT AGENCIES, OTHER HEALTHCARE PROVIDERS THAT WOULD ENABLE THE FILLING OF A NEED OR ENHANCE AND COMPLIMENT AN ALREADY EXISTING SERVICE. DATA IS GATHERED CONSTANTLY THROUGH BENCHMARKING, MARKET RESEARCH, CUSTOMER SURVEYS, PHYSICIAN INPUT, AND THROUGH CONSTANT MONITORING OF STATE AND FEDERAL GUIDELINES. THIS INFORMATION IS REVIEWED AND ANALYZED BY THE HOSPITAL'S SENIOR LEADERSHIP AND INCORPORATED INTO THE STRATEGIC PLANNING PROCESS. PART VI, LINE 3: SIGNS ARE POSTED IN THE FACILITY. THE PATIENT'S BILL INFORMS THEM OF THE FINANCIAL ASSISTANCE PROGRAM. THE HOSPITAL WEBSITE HAS A LINK TO THE FINANCIAL ASSISTANCE APPLICATION. THE SOCIAL SERVICES DEPARTMENT SPEAKS TO ALL INPATIENTS ABOUT THE PROGRAM. PART VI, LINE 4: FAIRFIELD MEMORIAL HOSPITAL SERVES THE POPULATION OF WAYNE COUNTY AND THE SURROUNDING COMMUNITIES WITHOUT REGARD TO AGE, GENDER, INCOME, ETHNIC ORIGIN, INSURANCE COVERAGE, OR ABILITY TO PAY. WAYNE COUNTY IS A RURAL AREA WITH AN ESTIMATED POPULATION OF 16,005. THE MEDIAN INCOME IN 2021 WAS $51,540, WHICH WAS 71.03% OF ILLINOIS'S AVERAGE. THE PERCENT OF INDIVIDUALS BELOW POVERTY WAS 14.3%. PART VI, LINE 5: FAIRFIELD MEMORIAL HOSPITAL HAS A COMMUNITY BOARD, MADE UP OF MEMBERS FROM DIFFERENT OCCUPATIONS IN THE COMMUNITY, INCLUDING MEDICAL, EDUCATION, LOCAL BUSINESSES, FARMING INDUSTRY AND BANKING. PART VI, LINE 7, REPORTS FILED WITH STATES IL X X X 0 0 0 0 0 0 0 0 0 KORY BLANK ORTHOPEDIC SURGEON 607372 0 124404 0 0 0 0 0 3167 0 734943 0 0 0 LOUIS REMYNSE UROLOGIST 365793 0 75094 0 0 0 0 0 5690 0 446577 0 0 0 CHRISTOPHER BALLARD PHYSICIAN 318627 0 14706 0 26000 0 5800 0 9683 0 374816 0 0 0 KATHERINE BUNTING CEO 272267 0 9875 0 71384 0 5800 0 10056 0 369382 0 0 0 ALEXIS KING CRNA 261569 0 94 0 80809 0 5800 0 3573 0 351845 0 0 0 MARLA LAFIKES PHYSICIAN 287693 0 94 0 19500 0 5800 0 11577 0 324664 0 0 0 BRADLEY AUGUST SON-IN-LAW OF CEO 104781 W-2 COMPENSATION 0 MELINDA BUNTING DAUGHTER-IN-LAW TO CEO 47249 W-2 COMPENSATION 0 ALLISSA KEOUGHAN DAUGHTER OF BOARD MEMBER 8892 W-2 COMPENSATION 0 DIANNA SENG SPOUSE OF BOARD MEMBER 28422 W-2 COMPENSATION 0 TRINA TROYER SISTER OF COO 26297 W-2 COMPENSATION 0 FORM 990, PART VI, SECTION B, LINE 11B THE CFO REVIEWS THE 990 AFTER IT IS COMPLETED, PRIOR TO BEING FINALIZED. ONCE REVIEWED, IT IS GIVEN TO THE CEO FOR REVIEW. AFTER THE DOCUMENT IS REVIEWED BY THE CEO, IT IS AVAILABLE FOR THE BOARD TO REVIEW. THE 990 PREPARERS ARE NOTIFIED THAT THE DOCUMENT IS APPROVED AND READY TO BE FILED WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C ANNUALLY, EACH BOARD MEMBER RECEIVES THE CORPORATE COMPLIANCE POLICY WHICH INCLUDES A CONFLICT OF INTEREST POLICY, TO REVIEW AND SIGN STATING THEY HAVE READ, AND DISCLOSED ANY CONFLICT OF INTERESTS; ALL SIGNED DOCUMENTS ARE KEPT ON FILE WITH THE ADMINISTRATION OFFICE. FORM 990, PART VI, SECTION B, LINE 15 IN FALL 2019, SEVERAL MARKET REPORTS WERE COMPILED AND REVIEWED, INCLUDING BECKERS HOSPITAL REVIEW, AND THE CEO COMPENSATION REPORT. THE CFO REQUESTED AND WAS PROVIDED DATA FROM THE AUDIT FIRM, WHO PROVIDED DATA OF CEO COMPENSATION BY SIZE OF HOSPITAL AND REGION. ALL REPORTS WERE PROVIDED BY THE CFO TO THE BOARD PRESIDENT FOR REVIEW. THE BOARD PRESIDENT THEN SUPPLIED THE DOCUMENTS TO THE COMPENSATION COMMITTEE, WHO REVIEWED THE DOCUMENTS AND ESTABLISHED A RATE FOR THE CEO. THE COMPENSATION COMMITTEE PRESENTED THE RATE TO THE FULL BOARD FOR APPROVAL. THE CEO'S CONTRACT IS IN EFFECT FOR 5 YEARS. LINE 15B: COMPENSATION FOR ALL OTHER OFFICERS OF THE ORGANIZATION IS DETERMINED BY THE BOARD BASED ON WEIGHTED PERFORMANCE APPRAISALS. FORM 990, PART VI, SECTION C, LINE 19 COPIES OF THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICIES, FINANCIAL STATEMENTS AND THE FEDERAL FORM 990 ARE AVAILABLE UPON REQUEST FROM THE ADMINISTRATIVE OFFICES. FORM 990, PART IX, LINE 11G PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 2,008,979. MANAGEMENT AND GENERAL EXPENSES 600,005. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,608,984. PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 1,080,007. MANAGEMENT AND GENERAL EXPENSES 322,556. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,402,563. COLLECTION FEES: PROGRAM SERVICE EXPENSES 80,803. MANAGEMENT AND GENERAL EXPENSES 24,133. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 104,936. PHYSICIAN FEES: PROGRAM SERVICE EXPENSES 1,715,525. MANAGEMENT AND GENERAL EXPENSES 512,361. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,227,886. DIAGNOSTIC MAMMOGRAPHY SERVICES : PROGRAM SERVICE EXPENSES 186,073. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 186,073. FAIRFIELD MEMORIAL HOSPITAL FOUNDATION 303 NW 11TH ST FAIRFIELD IL 62837 371185754 SUPPORT THE HOSPITAL IL 501(C)(3) LINE 12B, II N/A 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0