FAIRFIELD MEMORIAL HOSPITAL ASSOCIATION: Form 990, tax year 2021
View the entire original 990 at ProPublica ↗
- Organization
- FAIRFIELD MEMORIAL HOSPITAL ASSOCIATION (EIN 37-0661202)
- Tax period
- 2021-07-01 to 2022-06-30
- Filed
- 2023-05-10
- IRS object ID
- 202301309349303775
- Schema version
- 2021v4.2
- 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
- Form 990
- Schedule A
- Schedule B
- Schedule C
- Schedule D
- Schedule H
- Schedule I
- Schedule J
- Schedule L
- Schedule M
- Schedule O
- Schedule R
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return | 2023-05-10T13:45:14-05:00 | ReturnTs |
| Tax Period End | 2022-06-30 | TaxPeriodEndDt |
Preparer Firm PreparerFirmGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Firm EIN | 351178661 | PreparerFirmEIN |
Preparer Firm Name PreparerFirmName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | BLUE & CO LLC | BusinessNameLine1Txt |
Preparer US Address PreparerUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 2650 EASTPOINT PKWY SUITE 300 | AddressLine1Txt |
| City | LOUISVILLE | CityNm |
| State Abbreviation | KY | StateAbbreviationCd |
| ZIP | 40223 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnTypeCd |
| Tax Period Begin | 2021-07-01 | TaxPeriodBeginDt |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 370661202 | EIN |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | FAIRFIELD MEMORIAL HOSPITAL ASSOCIATION | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Control | FAIR | BusinessNameControlTxt |
| Phone | 6168422611 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 303 NW 11TH STREET | AddressLine1Txt |
| City | FAIRFIELD | CityNm |
| State Abbreviation | IL | StateAbbreviationCd |
| ZIP | 62837 | ZIPCd |
Business Officer BusinessOfficerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | AMY MARSH | PersonNm |
| Person Title | CFO | PersonTitleTxt |
| Phone | 6168422611 | PhoneNum |
| Signature | 2023-05-10 | SignatureDt |
| Discuss With Paid Preparer | Yes (1) | DiscussWithPaidPreparerInd |
Signing Officer SigningOfficerGrp
Person Full Name PersonFullName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person First | AMY | PersonFirstNm |
| Person Last | MARSH | PersonLastNm |
Preparer Person PreparerPersonGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Person | EMILIE M KNIERIEM CPA | PreparerPersonNm |
| PTIN | P01330194 | PTIN |
| Phone | 5029923500 | PhoneNum |
| Preparation | 2023-05-10 | PreparationDt |
Additional Filer Information AdditionalFilerInformation
Trusted Customer TrustedCustomerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Trusted Customer | 0 | TrustedCustomerCd |
| Authentication Assurance Level | AAL1 | AuthenticationAssuranceLevelCd |
| Identity Assurance Level | IAL1 | IdentityAssuranceLevelCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax | 2021 | TaxYr |
| Build TS | 2023-04-26 12:10:37Z | BuildTS |
Form 990 IRS990
| Field | Value | IRS element (for citing) |
|---|---|---|
| Principal Officer | KATHERINE BUNTING | PrincipalOfficerNm |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 303 NW 11TH STREET | AddressLine1Txt |
| City | FAIRFIELD | CityNm |
| State Abbreviation | IL | StateAbbreviationCd |
| ZIP | 62837 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | $48,296,657 | GrossReceiptsAmt |
| Group Return For Affiliates | 0 | GroupReturnForAffiliatesInd |
| Organization501c3 | Yes (X) | Organization501c3Ind |
| Website Address | FAIRFIELDMEMORIAL.ORG | WebsiteAddressTxt |
| Type Of Organization Corp | Yes (X) | TypeOfOrganizationCorpInd |
| Formation | 1948 | FormationYr |
| Legal Domicile State | IL | LegalDomicileStateCd |
| Activity Or Mission | THE MISSION OF FAIRFIELD MEMORIAL HOSPITAL IS TO MAINTAIN AND IMPROVE THE HEALTH OF THE COMMUNITIES WE SERVE. | ActivityOrMissionDesc |
| Voting Members Governing Body | 9 | VotingMembersGoverningBodyCnt |
| Voting Members Independent | 9 | VotingMembersIndependentCnt |
| Total Employee | 446 | TotalEmployeeCnt |
| Total Volunteers | 69 | TotalVolunteersCnt |
| Total Gross UBI | $0 | TotalGrossUBIAmt |
| Net Unrelated Bus Txbl Incm | $0 | NetUnrelatedBusTxblIncmAmt |
| PY Contributions Grants | $6,803,262 | PYContributionsGrantsAmt |
| CY Contributions Grants | $3,673,911 | CYContributionsGrantsAmt |
| PY Program Service Revenue | $36,165,428 | PYProgramServiceRevenueAmt |
| CY Program Service Revenue | $43,986,120 | CYProgramServiceRevenueAmt |
| PY Investment Income | $41,351 | PYInvestmentIncomeAmt |
| CY Investment Income | $52,981 | CYInvestmentIncomeAmt |
| PY Other Revenue | $653,087 | PYOtherRevenueAmt |
| CY Other Revenue | $583,645 | CYOtherRevenueAmt |
| PY Total Revenue | $43,663,128 | PYTotalRevenueAmt |
| CY Total Revenue | $48,296,657 | CYTotalRevenueAmt |
| PY Grants And Similar Paid | $0 | PYGrantsAndSimilarPaidAmt |
| CY Grants And Similar Paid | $56,887 | CYGrantsAndSimilarPaidAmt |
| PY Benefits Paid To Members | $0 | PYBenefitsPaidToMembersAmt |
| CY Benefits Paid To Members | $0 | CYBenefitsPaidToMembersAmt |
| PY Salaries Comp Emp Bnft Paid | $19,759,501 | PYSalariesCompEmpBnftPaidAmt |
| CY Salaries Comp Emp Bnft Paid | $22,750,678 | CYSalariesCompEmpBnftPaidAmt |
| PY Total Prof Fndrsng Expns | $0 | PYTotalProfFndrsngExpnsAmt |
| CY Total Prof Fndrsng Expns | $0 | CYTotalProfFndrsngExpnsAmt |
| CY Total Fundraising Expense | $0 | CYTotalFundraisingExpenseAmt |
| PY Other Expenses | $17,224,140 | PYOtherExpensesAmt |
| CY Other Expenses | $20,298,782 | CYOtherExpensesAmt |
| PY Total Expenses | $36,983,641 | PYTotalExpensesAmt |
| CY Total Expenses | $43,106,347 | CYTotalExpensesAmt |
| PY Revenues Less Expenses | $6,679,487 | PYRevenuesLessExpensesAmt |
| CY Revenues Less Expenses | $5,190,310 | CYRevenuesLessExpensesAmt |
| Total Assets BOY | $48,392,981 | TotalAssetsBOYAmt |
| Total Assets EOY | $57,270,866 | TotalAssetsEOYAmt |
| Total Liabilities BOY | $24,817,779 | TotalLiabilitiesBOYAmt |
| Total Liabilities EOY | $28,249,079 | TotalLiabilitiesEOYAmt |
| Net Assets Or Fund Balances BOY | $23,575,202 | NetAssetsOrFundBalancesBOYAmt |
| Net Assets Or Fund Balances EOY | $29,021,787 | NetAssetsOrFundBalancesEOYAmt |
| Info In Schedule O Part III | Yes (X) | InfoInScheduleOPartIIIInd |
| Mission | THE MISSION OF FAIRFIELD MEMORIAL HOSPITAL IS TO MAINTAIN AND IMPROVE THE HEALTH OF THE COMMUNITIES WE SERVE. | MissionDesc |
| Significant New Program Srvc | 0 | SignificantNewProgramSrvcInd |
| Significant Change | 0 | SignificantChangeInd |
| Expense | $37,909,462 | ExpenseAmt |
| Grant | $56,887 | GrantAmt |
| Revenue | $44,294,682 | RevenueAmt |
| Desc | 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 REGARDLESS OF RACE, CREED, SEX, NATIONAL ORIGIN, HANDICAP, AGE, 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. | Desc |
| Total Program Service Expenses | $37,909,462 | TotalProgramServiceExpensesAmt |
| Described In Section501c3 | Yes (1) | DescribedInSection501c3Ind |
| Schedule B Required | Yes (1) | ScheduleBRequiredInd |
| Political Campaign Acty | 0 | PoliticalCampaignActyInd |
| Lobbying Activities | Yes (1) | LobbyingActivitiesInd |
| Subject To Proxy Tax | 0 | SubjectToProxyTaxInd |
| Donor Advised Fund | 0 | DonorAdvisedFundInd |
| Conservation Easements | 0 | ConservationEasementsInd |
| Collections Of Art | 0 | CollectionsOfArtInd |
| Credit Counseling | 0 | CreditCounselingInd |
| Donor Rstr Or Quasi Endowments | 0 | DonorRstrOrQuasiEndowmentsInd |
| Report Land Building Equipment | Yes (1) | ReportLandBuildingEquipmentInd |
| Report Investments Other Sec | 0 | ReportInvestmentsOtherSecInd |
| Report Program Related Invst | 0 | ReportProgramRelatedInvstInd |
| Report Other Assets | 0 | ReportOtherAssetsInd |
| Report Other Liabilities | 0 | ReportOtherLiabilitiesInd |
| Include FIN48 Footnote | Yes (1) | IncludeFIN48FootnoteInd |
| Independent Audit Fincl Stmt | Yes (1) | IndependentAuditFinclStmtInd |
| Consolidated Audit Fincl Stmt | 0 | ConsolidatedAuditFinclStmtInd |
| School Operating | 0 | SchoolOperatingInd |
| Foreign Office | 0 | ForeignOfficeInd |
| Foreign Activities | 0 | ForeignActivitiesInd |
| More Than5000 K To Org | 0 | MoreThan5000KToOrgInd |
| More Than5000 K To Individuals | 0 | MoreThan5000KToIndividualsInd |
| Professional Fundraising | 0 | ProfessionalFundraisingInd |
| Fundraising Activities | 0 | FundraisingActivitiesInd |
| Gaming Activities | 0 | GamingActivitiesInd |
| Operate Hospital | Yes (1) | OperateHospitalInd |
| Audited Financial Stmt Att | Yes (1) | AuditedFinancialStmtAttInd |
| Grants To Organizations | 0 | GrantsToOrganizationsInd |
| Grants To Individuals | 0 | GrantsToIndividualsInd |
| Schedule J Required | Yes (1) | ScheduleJRequiredInd |
| Tax Exempt Bonds | 0 | TaxExemptBondsInd |
| Engaged In Excess Benefit Trans | 0 | EngagedInExcessBenefitTransInd |
| PY Excess Benefit Trans | 0 | PYExcessBenefitTransInd |
| Loan Outstanding | 0 | LoanOutstandingInd |
| Grant To Related Person | 0 | GrantToRelatedPersonInd |
| Business Rln With Org Mem | 0 | BusinessRlnWithOrgMemInd |
| Business Rln With Fam Mem | Yes (1) | BusinessRlnWithFamMemInd |
| Business Rln With35 Ctrl Ent | 0 | BusinessRlnWith35CtrlEntInd |
| Deductible Non Cash Contri | Yes (1) | DeductibleNonCashContriInd |
| Deductible Art Contribution | 0 | DeductibleArtContributionInd |
| Terminate Operations | 0 | TerminateOperationsInd |
| Partial Liquidation | 0 | PartialLiquidationInd |
| Disregarded Entity | 0 | DisregardedEntityInd |
| Related Entity | Yes (1) | RelatedEntityInd |
| Related Organization Ctrl Ent | 0 | RelatedOrganizationCtrlEntInd |
| Trnsfr Exmpt Non Chrtbl Rltd Org | 0 | TrnsfrExmptNonChrtblRltdOrgInd |
| Activities Conducted Prtshp | 0 | ActivitiesConductedPrtshpInd |
| Schedule O Required | Yes (1) | ScheduleORequiredInd |
| IRP Document | 26 | IRPDocumentCnt |
| IRP Document W2 G | 0 | IRPDocumentW2GCnt |
| Backup Wthld Compliance | Yes (1) | BackupWthldComplianceInd |
| Employee | 446 | EmployeeCnt |
| Employment Tax Returns Filed | Yes (1) | EmploymentTaxReturnsFiledInd |
| Unrelated Bus Incm Over Limit | 0 | UnrelatedBusIncmOverLimitInd |
| Foreign Financial Account | 0 | ForeignFinancialAccountInd |
| Prohibited Tax Shelter Trans | 0 | ProhibitedTaxShelterTransInd |
| Taxable Party Notification | 0 | TaxablePartyNotificationInd |
| Nondeductible Contributions | 0 | NondeductibleContributionsInd |
| Quid Pro Quo Contributions | 0 | QuidProQuoContributionsInd |
| Form8282 Property Disposed Of | 0 | Form8282PropertyDisposedOfInd |
| Rcv Fnds To Pay Prsnl Bnft Cntrct | 0 | RcvFndsToPayPrsnlBnftCntrctInd |
| Pay Premiums Prsnl Bnft Cntrct | 0 | PayPremiumsPrsnlBnftCntrctInd |
| Indoor Tanning Services | 0 | IndoorTanningServicesInd |
| Subj To Tax Rmnrtn Ex Prcht Pymt | 0 | SubjToTaxRmnrtnExPrchtPymtInd |
| Subject To Excs Tax Net Invst Inc | 0 | SubjectToExcsTaxNetInvstIncInd |
| Info In Schedule O Part VI | Yes (X) | InfoInScheduleOPartVIInd |
| Governing Body Voting Members | 9 | GoverningBodyVotingMembersCnt |
| Independent Voting Member | 9 | IndependentVotingMemberCnt |
| Family Or Business Rln | 0 | FamilyOrBusinessRlnInd |
| Delegation Of Mgmt Duties | 0 | DelegationOfMgmtDutiesInd |
| Change To Org Documents | 0 | ChangeToOrgDocumentsInd |
| Material Diversion Or Misuse | 0 | MaterialDiversionOrMisuseInd |
| Members Or Stockholders | 0 | MembersOrStockholdersInd |
| Election Of Board Members | 0 | ElectionOfBoardMembersInd |
| Decisions Subject To Approva | 0 | DecisionsSubjectToApprovaInd |
| Minutes Of Governing Body | Yes (1) | MinutesOfGoverningBodyInd |
| Minutes Of Committees | Yes (1) | MinutesOfCommitteesInd |
| Officer Mailing Address | 0 | OfficerMailingAddressInd |
| Local Chapters | 0 | LocalChaptersInd |
| Form990 Provided To Gvrn Body | Yes (1) | Form990ProvidedToGvrnBodyInd |
| Conflict Of Interest Policy | Yes (1) | ConflictOfInterestPolicyInd |
| Annual Disclosure Covered Prsn | Yes (1) | AnnualDisclosureCoveredPrsnInd |
| Regular Monitoring Enfrc | Yes (1) | RegularMonitoringEnfrcInd |
| Whistleblower Policy | Yes (1) | WhistleblowerPolicyInd |
| Document Retention Policy | Yes (1) | DocumentRetentionPolicyInd |
| Compensation Process CEO | Yes (1) | CompensationProcessCEOInd |
| Compensation Process Other | 0 | CompensationProcessOtherInd |
| Investment In Joint Venture | 0 | InvestmentInJointVentureInd |
| States Where Copy Of Return Is Fld | IL | StatesWhereCopyOfReturnIsFldCd |
| Upon Request | Yes (X) | UponRequestInd |
Books In Care Of Detail BooksInCareOfDetail
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | AMY L MARSH | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Phone | 6188478260 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 303 NW 11TH | AddressLine1Txt |
| City | FAIRFIELD | CityNm |
| State Abbreviation | IL | StateAbbreviationCd |
| ZIP | 62837 | ZIPCd |
Form990 Part VII Section A Form990PartVIISectionAGrp (20 entries)
| TitleTitleTxt | Average Hours Per WeekAverageHoursPerWeekRt | Highest Compensated EmployeeHighestCompensatedEmployeeInd | Reportable Comp From OrgReportableCompFromOrgAmt | Reportable Comp From Rltd OrgReportableCompFromRltdOrgAmt | Other CompensationOtherCompensationAmt | OfficerOfficerInd | Individual Trustee Or DirectorIndividualTrusteeOrDirectorInd |
|---|---|---|---|---|---|---|---|
| CHRISTOPHER BALLARD | |||||||
| PHYSICIAN | 40.00 | Yes (X) | $362,890 | $0 | $20,513 | ||
| MARLA LAFIKES | |||||||
| PHYSICIAN | 40.00 | Yes (X) | $335,460 | $0 | $20,148 | ||
| KATHERINE BUNTING | |||||||
| CEO | 40.00 | $313,702 | $0 | $14,121 | Yes (X) | ||
| KORY BLANK | |||||||
| ORTHOPEDIC SURGEON | 40.00 | Yes (X) | $287,529 | $0 | $28,224 | ||
| ALEXIS KING | |||||||
| CRNA | 40.00 | Yes (X) | $261,123 | $0 | $19,462 | ||
| KIMBERLY KING | |||||||
| CRNA | 40.00 | Yes (X) | $251,818 | $0 | $10,770 | ||
| DANA TAYLOR | |||||||
| COO | 40.00 | $132,089 | $0 | $9,292 | Yes (X) | ||
| HAZEL VEST | |||||||
| CNO (BEG 09/21) | 40.00 | $124,689 | $0 | $15,228 | Yes (X) | ||
| AMY MARSH | |||||||
| CFO | 40.00 | $130,093 | $0 | $9,071 | Yes (X) | ||
| CHRISTINA BAKER | |||||||
| CNO (END 09/21) | 40.00 | $78,852 | $0 | $1,399 | Yes (X) | ||
| PATRICK MOLT MD | |||||||
| PRESIDENT | 1.75 | $0 | $0 | $0 | Yes (X) | Yes (X) | |
| JOEY HUNGERFORD | |||||||
| VICE PRESIDENT | 1.75 | $0 | $0 | $0 | Yes (X) | Yes (X) | |
| ANITA POND | |||||||
| SECRETARY/TREASURER | 1.75 | $0 | $0 | $0 | Yes (X) | Yes (X) | |
| MICHAEL COPELAND | |||||||
| DIRECTOR | 1.25 | $0 | $0 | $0 | Yes (X) | ||
| DONNA MASTERSON | |||||||
| DIRECTOR | 1.25 | $0 | $0 | $0 | Yes (X) | ||
| D JAMIE POLLARD | |||||||
| DIRECTOR | 1.25 | $0 | $0 | $0 | Yes (X) | ||
| MATTHEW SENG | |||||||
| DIRECTOR | 1.25 | $0 | $0 | $0 | Yes (X) | ||
| DOUG WILSON | |||||||
| DIRECTOR | 1.25 | $0 | $0 | $0 | Yes (X) | ||
| JARED VAUGHN | |||||||
| DIRECTOR (END 10/21) | 1.25 | $0 | $0 | $0 | Yes (X) | ||
| TOBY HUCKER | |||||||
| DIRECTOR | 1.25 | $0 | $0 | $0 | Yes (X) | ||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | $2,278,245 | TotalReportableCompFromOrgAmt |
| Tot Reportable Comp Rltd Org | $0 | TotReportableCompRltdOrgAmt |
| Total Other Compensation | $148,228 | TotalOtherCompensationAmt |
| Indiv Rcvd Greater Than100 K | 20 | IndivRcvdGreaterThan100KCnt |
| Former Ofcr Employees Listed | 0 | FormerOfcrEmployeesListedInd |
| Total Comp Greater Than150 K | Yes (1) | TotalCompGreaterThan150KInd |
| Compensation From Other Srcs | 0 | CompensationFromOtherSrcsInd |
Contractor Compensation ContractorCompensationGrp (5 entries)
| Address Line1ContractorAddress/USAddress/AddressLine1Txt | CityContractorAddress/USAddress/CityNm | State AbbreviationContractorAddress/USAddress/StateAbbreviationCd | ZIPContractorAddress/USAddress/ZIPCd | ServicesServicesDesc | CompensationCompensationAmt |
|---|---|---|---|---|---|
| DR RODNEY BEELER | |||||
| 2142 KETTLE HILL CT | EVANSVILLE | IN | 47725 | ER PHYSICIAN | $403,716 |
| DR DOUGLAS FRANKEL | |||||
| 407 S MARKET STREET | MARION | IL | 62959 | ER PHYSICIAN | $398,137 |
| DR JASIRI KENNEDY | |||||
| 11817 BORDEN ROAD | HERALD | CA | 956389707 | ER PHYSICIAN | $378,395 |
| DR SCOTT ROUSTIO | |||||
| 8422 BRAESWOOD ESTATES DRIVE | OFALLON | IL | 62269 | ER PHYSICIAN | $197,309 |
| DR MARK ROTICH | |||||
| 1401 DANIELLE CT | MARION | IL | 62959 | ER PHYSICIAN | $177,332 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cntrct Rcvd Greater Than100 K | 8 | CntrctRcvdGreaterThan100KCnt |
| Government Grants | $53,125 | GovernmentGrantsAmt |
| All Other Contributions | $3,620,786 | AllOtherContributionsAmt |
| Noncash Contributions | $3,006,616 | NoncashContributionsAmt |
| Total Contributions | $3,673,911 | TotalContributionsAmt |
Program Service Revenue ProgramServiceRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Desc | NET PATIENT REVENUE | Desc |
| Business | 621999 | BusinessCd |
| Total Revenue Column | $43,986,120 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $43,986,120 | RelatedOrExemptFuncIncomeAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | $43,986,120 | TotalProgramServiceRevenueAmt |
Investment Income InvestmentIncomeGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $52,981 | TotalRevenueColumnAmt |
| Exclusion | $52,981 | ExclusionAmt |
Gross Rents GrossRentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $265,739 | RealAmt |
Less Rental Expenses LessRentalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $0 | RealAmt |
Rental Income Or Loss RentalIncomeOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $265,739 | RealAmt |
Net Rental Income Or Loss NetRentalIncomeOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $265,739 | TotalRevenueColumnAmt |
| Exclusion | $265,739 | ExclusionAmt |
Other Revenue Misc OtherRevenueMiscGrp (3 entries)
| DescDesc | BusinessBusinessCd | Total Revenue ColumnTotalRevenueColumnAmt | Related Or Exempt Func IncomeRelatedOrExemptFuncIncomeAmt | ExclusionExclusionAmt |
|---|---|---|---|---|
| PROFESSIONAL LIABILITY INSURANCE | 900099 | $219,248 | $219,248 | |
| CAFETERIA & CATERING | 722310 | $64,161 | $54,817 | $9,344 |
| MEDICAL RECORDS | 900099 | $10,197 | $10,197 |
Miscellaneous Revenue MiscellaneousRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $24,300 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $24,300 | RelatedOrExemptFuncIncomeAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Revenue Total | $317,906 | OtherRevenueTotalAmt |
Total Revenue TotalRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $48,296,657 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $44,294,682 | RelatedOrExemptFuncIncomeAmt |
| Unrelated Business Revenue | $0 | UnrelatedBusinessRevenueAmt |
| Exclusion | $328,064 | ExclusionAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part IX | Yes (X) | InfoInScheduleOPartIXInd |
Grants To Domestic Orgs GrantsToDomesticOrgsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $56,887 | TotalAmt |
| Program Services | $56,887 | ProgramServicesAmt |
Comp Current Ofcr Directors CompCurrentOfcrDirectorsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $767,672 | TotalAmt |
| Program Services | $686,586 | ProgramServicesAmt |
| Management And General | $81,086 | ManagementAndGeneralAmt |
Other Salaries And Wages OtherSalariesAndWagesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $17,452,815 | TotalAmt |
| Program Services | $15,609,338 | ProgramServicesAmt |
| Management And General | $1,843,477 | ManagementAndGeneralAmt |
Pension Plan Contributions PensionPlanContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $175,959 | TotalAmt |
| Program Services | $157,373 | ProgramServicesAmt |
| Management And General | $18,586 | ManagementAndGeneralAmt |
Other Employee Benefits OtherEmployeeBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $3,101,137 | TotalAmt |
| Program Services | $2,773,575 | ProgramServicesAmt |
| Management And General | $327,562 | ManagementAndGeneralAmt |
Payroll Taxes PayrollTaxesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,253,095 | TotalAmt |
| Program Services | $1,120,736 | ProgramServicesAmt |
| Management And General | $132,359 | ManagementAndGeneralAmt |
Fees For Services Legal FeesForServicesLegalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $39,430 | TotalAmt |
| Management And General | $39,430 | ManagementAndGeneralAmt |
Fees For Services Accounting FeesForServicesAccountingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $118,884 | TotalAmt |
| Management And General | $118,884 | ManagementAndGeneralAmt |
Fees For Services Other FeesForServicesOtherGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $5,616,362 | TotalAmt |
| Program Services | $4,324,731 | ProgramServicesAmt |
| Management And General | $1,291,631 | ManagementAndGeneralAmt |
Advertising AdvertisingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $287,035 | TotalAmt |
| Program Services | $91,694 | ProgramServicesAmt |
| Management And General | $195,341 | ManagementAndGeneralAmt |
Office Expenses OfficeExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $990,632 | TotalAmt |
| Program Services | $925,010 | ProgramServicesAmt |
| Management And General | $65,622 | ManagementAndGeneralAmt |
Occupancy OccupancyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $827,291 | TotalAmt |
| Program Services | $827,291 | ProgramServicesAmt |
Travel TravelGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $130,800 | TotalAmt |
| Program Services | $41,784 | ProgramServicesAmt |
| Management And General | $89,016 | ManagementAndGeneralAmt |
Interest InterestGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $351,749 | TotalAmt |
| Program Services | $248,113 | ProgramServicesAmt |
| Management And General | $103,636 | ManagementAndGeneralAmt |
Depreciation Depletion DepreciationDepletionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,602,589 | TotalAmt |
| Program Services | $1,602,589 | ProgramServicesAmt |
Insurance InsuranceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $263,710 | TotalAmt |
| Management And General | $263,710 | ManagementAndGeneralAmt |
Other Expenses OtherExpensesGrp (4 entries)
| DescDesc | TotalTotalAmt | Program ServicesProgramServicesAmt | Management And GeneralManagementAndGeneralAmt |
|---|---|---|---|
| MEDICAL SUPPLIES & DRUG | $7,375,594 | $7,375,594 | |
| REPAIRS & MAINTENANCE | $925,116 | $672,575 | $252,541 |
| MEDICAID ASSESSMENT TAX | $885,416 | $885,416 | |
| FOOD EXPENSE | $334,611 | $334,611 |
All Other Expenses AllOtherExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $549,563 | TotalAmt |
| Program Services | $175,559 | ProgramServicesAmt |
| Management And General | $374,004 | ManagementAndGeneralAmt |
Total Functional Expenses TotalFunctionalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $43,106,347 | TotalAmt |
| Program Services | $37,909,462 | ProgramServicesAmt |
| Management And General | $5,196,885 | ManagementAndGeneralAmt |
| Fundraising | $0 | FundraisingAmt |
Cash Non Interest Bearing CashNonInterestBearingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,432 | BOYAmt |
| EOY | $2,781,281 | EOYAmt |
Savings And Temp Cash Invst SavingsAndTempCashInvstGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $9,756,584 | BOYAmt |
| EOY | $3,682,279 | EOYAmt |
Accounts Receivable AccountsReceivableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $5,223,700 | BOYAmt |
| EOY | $8,157,768 | EOYAmt |
Oth Notes Loans Receivable Net OthNotesLoansReceivableNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,056,562 | BOYAmt |
| EOY | $2,563,487 | EOYAmt |
Inventories For Sale Or Use InventoriesForSaleOrUseGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $649,434 | BOYAmt |
| EOY | $1,155,014 | EOYAmt |
Prepaid Expenses Defrd Charges PrepaidExpensesDefrdChargesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $956,292 | BOYAmt |
| EOY | $428,199 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Bldg Equip Cost Or Other Bss | $68,422,477 | LandBldgEquipCostOrOtherBssAmt |
| Land Bldg Equip Accum Deprec | $29,979,107 | LandBldgEquipAccumDeprecAmt |
Land Bldg Equip Basis Net LandBldgEquipBasisNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $30,627,215 | BOYAmt |
| EOY | $38,443,370 | EOYAmt |
Investments Pub Traded Sec InvestmentsPubTradedSecGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $800 | BOYAmt |
| EOY | $1,761 | EOYAmt |
Other Assets Total OtherAssetsTotalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $120,962 | BOYAmt |
| EOY | $57,707 | EOYAmt |
Total Assets TotalAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $48,392,981 | BOYAmt |
| EOY | $57,270,866 | EOYAmt |
Accounts Payable Accr Expnss AccountsPayableAccrExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $6,363,876 | BOYAmt |
| EOY | $5,831,816 | EOYAmt |
Deferred Revenue DeferredRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| EOY | $559,604 | EOYAmt |
Mortg Notes Pybl Scrd Invst Prop MortgNotesPyblScrdInvstPropGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $17,938,643 | BOYAmt |
| EOY | $21,857,659 | EOYAmt |
Unsecured Notes Loans Payable UnsecuredNotesLoansPayableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $515,260 | BOYAmt |
| EOY | $0 | EOYAmt |
Total Liabilities TotalLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $24,817,779 | BOYAmt |
| EOY | $28,249,079 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Organization Follows FASB117 | Yes (X) | OrganizationFollowsFASB117Ind |
No Donor Restriction Net Assets NoDonorRestrictionNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $22,952,422 | BOYAmt |
| EOY | $28,819,241 | EOYAmt |
Donor Restriction Net Assets DonorRestrictionNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $622,780 | BOYAmt |
| EOY | $202,546 | EOYAmt |
Total Net Assets Fund Balance TotalNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $23,575,202 | BOYAmt |
| EOY | $29,021,787 | EOYAmt |
Tot Liab Net Assets Fund Balance TotLiabNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $48,392,981 | BOYAmt |
| EOY | $57,270,866 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Reconcilation Revenue Expnss | $5,190,310 | ReconcilationRevenueExpnssAmt |
| Prior Period Adjustments | $256,275 | PriorPeriodAdjustmentsAmt |
| Other Changes In Net Assets | $0 | OtherChangesInNetAssetsAmt |
| Method Of Accounting Accrual | Yes (X) | MethodOfAccountingAccrualInd |
| Accountant Compile Or Review | 0 | AccountantCompileOrReviewInd |
| FS Audited | Yes (1) | FSAuditedInd |
FS Audited Basis FSAuditedBasisGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Separate Basis Fincl Stmt | Yes (X) | SeparateBasisFinclStmtInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Audit Committee | Yes (1) | AuditCommitteeInd |
| Federal Grant Audit Required | Yes (1) | FederalGrantAuditRequiredInd |
| Federal Grant Audit Performed | Yes (1) | FederalGrantAuditPerformedInd |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Hospital | Yes (X) | HospitalInd |
Schedule B IRS990ScheduleB
Contributor Information ContributorInformationGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Contributor | RESTRICTED | ContributorNum |
Contributor Business Name ContributorBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | RESTRICTED | BusinessNameLine1 |
Contributor US Address ContributorUSAddress
| 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) |
|---|---|---|
| Total Contributions | RESTRICTED | TotalContributionsAmt |
Schedule C IRS990ScheduleC
| Field | Value | IRS element (for citing) |
|---|---|---|
| Volunteers | 0 | VolunteersInd |
| Paid Staff Or Management | 0 | PaidStaffOrManagementInd |
| Media Advertisements | 0 | MediaAdvertisementsInd |
| Mailings Members | 0 | MailingsMembersInd |
| Publications Or Broadcast | 0 | PublicationsOrBroadcastInd |
| Grants Other Organizations | 0 | GrantsOtherOrganizationsInd |
| Direct Contact Legislators | 0 | DirectContactLegislatorsInd |
| Rallies Demonstrations | 0 | RalliesDemonstrationsInd |
| Other Activities | Yes (1) | OtherActivitiesInd |
| Other Activities | $9,277 | OtherActivitiesAmt |
| Total Lobbying Expenditures | $9,277 | TotalLobbyingExpendituresAmt |
| Not Described Section501c3 | 0 | NotDescribedSection501c3Ind |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | PART II-B, LINE 1: | FormAndLineReferenceDesc |
| Explanation | FMH PAID FOR IHA MEMBERSHIP DUES IN FYE 2022. THE PORTION OF MEMBERSHIP DUES ATTRIBUTABLE TOWARDS LOBBYING EXPENDITURES WERE 37%. | ExplanationTxt |
Schedule D IRS990ScheduleD
Land LandGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $449,428 | OtherCostOrOtherBasisAmt |
| Book Value | $449,428 | BookValueAmt |
Buildings BuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $24,566,450 | OtherCostOrOtherBasisAmt |
| Depreciation | $15,614,368 | DepreciationAmt |
| Book Value | $8,952,082 | BookValueAmt |
Equipment EquipmentGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $16,534,658 | OtherCostOrOtherBasisAmt |
| Depreciation | $13,581,907 | DepreciationAmt |
| Book Value | $2,952,751 | BookValueAmt |
Other Land Buildings OtherLandBuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $26,871,941 | OtherCostOrOtherBasisAmt |
| Depreciation | $782,832 | DepreciationAmt |
| Book Value | $26,089,109 | BookValueAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Land Buildings | $38,443,370 | TotalBookValueLandBuildingsAmt |
| Footnote Text | Yes (X) | FootnoteTextInd |
| Total Rev Etc Audited Fincl Stmt | $48,296,657 | TotalRevEtcAuditedFinclStmtAmt |
| Revenue Not Reported | $0 | RevenueNotReportedAmt |
| Revenue Subtotal | $48,296,657 | RevenueSubtotalAmt |
| Revenue Not Reported Fincl Stmt | $0 | RevenueNotReportedFinclStmtAmt |
| Total Revenue Per Form990 | $48,296,657 | TotalRevenuePerForm990Amt |
| Tot Expns Etc Audited Fincl Stmt | $43,106,347 | TotExpnsEtcAuditedFinclStmtAmt |
| Expenses Not Reported | $0 | ExpensesNotReportedAmt |
| Expenses Subtotal | $43,106,347 | ExpensesSubtotalAmt |
| Expenses Not Rpt Fincl Stmt | $0 | ExpensesNotRptFinclStmtAmt |
| Total Expenses Per Form990 | $43,106,347 | TotalExpensesPerForm990Amt |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | PART X, LINE 2: | FormAndLineReferenceDesc |
| Explanation | 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. | ExplanationTxt |
Schedule H IRS990ScheduleH
| Field | Value | IRS element (for citing) |
|---|---|---|
| Financial Assistance Policy | Yes (1) | FinancialAssistancePolicyInd |
| Written Policy | Yes (1) | WrittenPolicyInd |
| All Hospitals Policy | Yes (X) | AllHospitalsPolicyInd |
| FPG Reference Free Care | Yes (1) | FPGReferenceFreeCareInd |
| Percent200 | Yes (X) | Percent200Ind |
| FPG Reference Discounted Care | Yes (1) | FPGReferenceDiscountedCareInd |
| Percent300 | Yes (X) | Percent300Ind |
| Free Care Medically Indigent | Yes (1) | FreeCareMedicallyIndigentInd |
| Financial Assistance Budget | Yes (1) | FinancialAssistanceBudgetInd |
| Expenses Exceed Budget | 0 | ExpensesExceedBudgetInd |
| Annual Community Bnft Report | 0 | AnnualCommunityBnftReportInd |
Financial Assistance At Cost Typ FinancialAssistanceAtCostTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $208,979 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $0 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $208,979 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00480 | TotalExpensePct |
Unreimbursed Medicaid UnreimbursedMedicaidGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $8,081,899 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $4,304,004 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $3,777,895 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.08760 | TotalExpensePct |
Total Financial Assistance Typ TotalFinancialAssistanceTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $8,290,878 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $4,304,004 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $3,986,874 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.09240 | TotalExpensePct |
Health Professions Education HealthProfessionsEducationGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $426,876 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $0 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $426,876 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00990 | TotalExpensePct |
Cash And In Kind Contributions CashAndInKindContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $12,176 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $0 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $12,176 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00030 | TotalExpensePct |
Total Other Benefits TotalOtherBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $439,052 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $439,052 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.01020 | TotalExpensePct |
Total Community Benefits TotalCommunityBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $8,729,930 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $4,304,004 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $4,425,926 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.10260 | TotalExpensePct |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | Yes (1) | BadDebtExpenseReportedInd |
| Bad Debt Expense | $770,849 | BadDebtExpenseAmt |
| Bad Debt Expense Attributable | $192,712 | BadDebtExpenseAttributableAmt |
| Reimbursed By Medicare | $7,064,578 | ReimbursedByMedicareAmt |
| Cost Of Care Reimbursed By Medcr | $10,962,294 | CostOfCareReimbursedByMedcrAmt |
| Medicare Surplus Or Shortfall | -$3,897,716 | MedicareSurplusOrShortfallAmt |
Costing Methodology Used CostingMethodologyUsedGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cost To Charge Ratio | Yes (X) | CostToChargeRatioInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Written Debt Collection Policy | Yes (1) | WrittenDebtCollectionPolicyInd |
| Financial Assistance Prvsn | Yes (1) | FinancialAssistancePrvsnInd |
| Hospital Facilities | 1 | HospitalFacilitiesCnt |
Hospital Facilities HospitalFacilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | FAIRFIELD MEMORIAL HOSPITAL | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 303 NW 11TH STREET | AddressLine1Txt |
| City | FAIRFIELD | CityNm |
| State Abbreviation | IL | StateAbbreviationCd |
| ZIP | 62837 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Website Address | WWW.FAIRFIELDMEMORIAL.ORG | WebsiteAddressTxt |
| State License | 320005545 | StateLicenseNum |
| Licensed Hospital | Yes (X) | LicensedHospitalInd |
| General Medical And Surgical | Yes (X) | GeneralMedicalAndSurgicalInd |
| Critical Access Hospital | Yes (X) | CriticalAccessHospitalInd |
| Emergency Room24 Hrs | Yes (X) | EmergencyRoom24HrsInd |
Hospital Fclty Policies Prctc HospitalFcltyPoliciesPrctcGrp
Hospital Facility Name HospitalFacilityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | FAIRFIELD MEMORIAL HOSPITAL | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
| First Licensed CY Or PY | 0 | FirstLicensedCYOrPYInd |
| Tax Exempt Hospital CY Or PY | 0 | TaxExemptHospitalCYOrPYInd |
| CHNA Conducted | Yes (1) | CHNAConductedInd |
| Community Definition | Yes (X) | CommunityDefinitionInd |
| Community Demographics | Yes (X) | CommunityDemographicsInd |
| Existing Resources | Yes (X) | ExistingResourcesInd |
| How Data Obtained | Yes (X) | HowDataObtainedInd |
| Community Health Needs | Yes (X) | CommunityHealthNeedsInd |
| Other Health Issues | Yes (X) | OtherHealthIssuesInd |
| Community Hlth Needs Id Process | Yes (X) | CommunityHlthNeedsIdProcessInd |
| Consulting Process | Yes (X) | ConsultingProcessInd |
| Prior CHNA Impact | Yes (X) | PriorCHNAImpactInd |
| CHNA Conducted | 22 | CHNAConductedYr |
| Take Into Account Others Input | Yes (1) | TakeIntoAccountOthersInputInd |
| CHNA Conducted With Other Fclts | 0 | CHNAConductedWithOtherFcltsInd |
| CHNA Conducted With Non Fclts | 0 | CHNAConductedWithNonFcltsInd |
| CHNA Report Widely Available | Yes (1) | CHNAReportWidelyAvailableInd |
| Rpt Available On Own Website | Yes (X) | RptAvailableOnOwnWebsiteInd |
| Own Website URL | WWW.FAIRFIELDMEMORIAL.ORG/RESOURCES/COMMUNITY-REPORTS/ | OwnWebsiteURLTxt |
| Paper Copy Public Inspection | Yes (X) | PaperCopyPublicInspectionInd |
| Implementation Strategy Adopt | Yes (1) | ImplementationStrategyAdoptInd |
| Implementation Strategy Adpt | 22 | ImplementationStrategyAdptYr |
| Strategy Posted Website | Yes (1) | StrategyPostedWebsiteInd |
| Strategy Website URL | WWW.FAIRFIELDMEMORIAL.ORG/RESOURCES/COMMUNITY-REPORTS/ | StrategyWebsiteURLTxt |
| Organization Incur Excise Tax | 0 | OrganizationIncurExciseTaxInd |
| Elig Criteria Explained | Yes (1) | EligCriteriaExplainedInd |
| FPG Family Incm Lmt Free Dscnt | Yes (X) | FPGFamilyIncmLmtFreeDscntInd |
| FPG Family Incm Lmt Free Care | 200.000000000000 | FPGFamilyIncmLmtFreeCarePct |
| FPG Family Incm Lmt Dscnt Care | 300.000000000000 | FPGFamilyIncmLmtDscntCarePct |
| Medical Indigency Criteria | Yes (X) | MedicalIndigencyCriteriaInd |
| Insurance Status Criteria | Yes (X) | InsuranceStatusCriteriaInd |
| Explained Basis | Yes (1) | ExplainedBasisInd |
| App Financial Asst Expln | Yes (1) | AppFinancialAsstExplnInd |
| Described Info | Yes (X) | DescribedInfoInd |
| Described Suprt Doc | Yes (X) | DescribedSuprtDocInd |
| Provided Hospital Contact | Yes (X) | ProvidedHospitalContactInd |
| Includes Publicity Measures | Yes (1) | IncludesPublicityMeasuresInd |
| FAP Available On Website | Yes (X) | FAPAvailableOnWebsiteInd |
| FAP Available On Website URL | WWW.FAIRFIELDMEMORIAL.ORG/ASSISTANCE/FINANCIAL-ASSISTANCE/ | FAPAvailableOnWebsiteURLTxt |
| FAP App Available On Website | Yes (X) | FAPAppAvailableOnWebsiteInd |
| FAP App Available On Website URL | WWW.FAIRFIELDMEMORIAL.ORG/ASSISTANCE/FINANCIAL-ASSISTANCE/ | FAPAppAvailableOnWebsiteURLTxt |
| FAP Summary On Website | Yes (X) | FAPSummaryOnWebsiteInd |
| FAP Summary On Website URL | WWW.FAIRFIELDMEMORIAL.ORG/ASSISTANCE/FINANCIAL-ASSISTANCE/ | FAPSummaryOnWebsiteURLTxt |
| FAP Avlbl On Request No Charge | Yes (X) | FAPAvlblOnRequestNoChargeInd |
| FAP App Avlbl On Request No Chrg | Yes (X) | FAPAppAvlblOnRequestNoChrgInd |
| FAP Sum Avlbl On Request No Chrg | Yes (X) | FAPSumAvlblOnRequestNoChrgInd |
| Notified FAP Copy Bill Display | Yes (X) | NotifiedFAPCopyBillDisplayInd |
| Communtity Notified FAP | Yes (X) | CommuntityNotifiedFAPInd |
| FAP Translated | Yes (X) | FAPTranslatedInd |
| FAP Actions On Nonpayment | Yes (1) | FAPActionsOnNonpaymentInd |
| Permit No Actions | Yes (X) | PermitNoActionsInd |
| Collection Activities | 0 | CollectionActivitiesInd |
| Provided Written Notice | Yes (X) | ProvidedWrittenNoticeInd |
| Made Effort Orally Notify | Yes (X) | MadeEffortOrallyNotifyInd |
| Processed FAP Application | Yes (X) | ProcessedFAPApplicationInd |
| Made Presumptive Elig Determ | Yes (X) | MadePresumptiveEligDetermInd |
| Nondis Emergency Care Policy | Yes (1) | NondisEmergencyCarePolicyInd |
| Look Back Medicare | Yes (X) | LookBackMedicareInd |
| Amounts Generally Billed | 0 | AmountsGenerallyBilledInd |
| Gross Charges | 0 | GrossChargesInd |
Supplemental Information SupplementalInformationGrp (2 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| 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. |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
Oth Hlth Care Fclts Not Hospital OthHlthCareFcltsNotHospitalGrp
Oth Hlth Care Fclts OthHlthCareFcltsGrp
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | 1 - HORIZON HEALTHCARE | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 213 NW 10TH STREET STE A | AddressLine1Txt |
| City | FAIRFIELD | CityNm |
| State Abbreviation | IL | StateAbbreviationCd |
| ZIP | 62837 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | OUTPATIENT PHYSICIAN CLINIC | FacilityTxt |
Supplemental Information Detail SupplementalInformationDetail (11 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| 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 FYE2022 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 |
Schedule I IRS990ScheduleI
| Field | Value | IRS element (for citing) |
|---|---|---|
| Grant Records Maintained | Yes (1) | GrantRecordsMaintainedInd |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | PART I, LINE 2: | FormAndLineReferenceDesc |
| Explanation | FMH DOES NOT GIVE GRANTS. WE DO GIVE DONATIONS TO LOCAL 501(C)(3) ORGANIZATIONS, INCLUDING FRONTIER COMMUNITY COLLEGE, AREA SCHOOLS AND LOCAL CHAMBER OF COMMERCE, LOCAL GIRL SCOUT TROOPS, AND AMERICAN CANCER SOCIETY. AS NO DONATIONS EXCEED $5,000, AN INVOICE OR THANK YOU LETTER FROM THE ORGANIZATON IS KEPT AS DOCUMENTATION. IN ADDITION, THE HOSPITAL VERIFIES THAT THE ORGANIZATION IS A 501(C)(3) PRIOR TO DONATING FUNDS. THE ONLY EXCEPTION TO THE REQUIREMENT OF A 501(C)(3) WAS A DONATION TO THE FAMILY OF A WAYNE COUNTY DEPUTY WHO LOST HIS LIFE IN THE LINE OF DUTY. | ExplanationTxt |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Compensation Committee | Yes (X) | CompensationCommitteeInd |
| Written Employment Contract | Yes (X) | WrittenEmploymentContractInd |
| Compensation Survey | Yes (X) | CompensationSurveyInd |
| Board Or Committee Approval | Yes (X) | BoardOrCommitteeApprovalInd |
| Severance Payment | 0 | SeverancePaymentInd |
| Supplemental Nonqual Rtr Plan | 0 | SupplementalNonqualRtrPlanInd |
| Equity Based Comp Arrngm | 0 | EquityBasedCompArrngmInd |
| Comp Based On Revenue Of Flng Org | 0 | CompBasedOnRevenueOfFlngOrgInd |
| Comp Bsd On Rev Related Orgs | 0 | CompBsdOnRevRelatedOrgsInd |
| Comp Bsd Net Earns Flng Org | 0 | CompBsdNetEarnsFlngOrgInd |
| Comp Bsd Net Earns Rltd Orgs | 0 | CompBsdNetEarnsRltdOrgsInd |
| Any Non Fixed Payments | 0 | AnyNonFixedPaymentsInd |
| Initial Contract Exception | 0 | InitialContractExceptionInd |
Rltd Org Officer Trst Key Empl RltdOrgOfficerTrstKeyEmplGrp (6 entries)
| TitleTitleTxt | Base Compensation Filing OrgBaseCompensationFilingOrgAmt | Compensation Based On Rltd OrgsCompensationBasedOnRltdOrgsAmt | Bonus Filing OrganizationBonusFilingOrganizationAmount | Bonus Related OrganizationsBonusRelatedOrganizationsAmt | Other Compensation Filing OrgOtherCompensationFilingOrgAmt | Other Compensation Rltd OrgsOtherCompensationRltdOrgsAmt | Deferred Compensation Flng OrgDeferredCompensationFlngOrgAmt | Deferred Comp Rltd OrgsDeferredCompRltdOrgsAmt | Nontaxable Benefits Filing OrgNontaxableBenefitsFilingOrgAmt | Nontaxable Benefits Rltd OrgsNontaxableBenefitsRltdOrgsAmt | Total Compensation Filing OrgTotalCompensationFilingOrgAmt | Total Compensation Rltd OrgsTotalCompensationRltdOrgsAmt | Comp Report Prior990 Filing OrgCompReportPrior990FilingOrgAmt | Comp Report Prior990 Rltd OrgsCompReportPrior990RltdOrgsAmt |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| CHRISTOPHER BALLARD | ||||||||||||||
| PHYSICIAN | $362,890 | $0 | $0 | $0 | $0 | $0 | $13,571 | $0 | $6,942 | $0 | $383,403 | $0 | $0 | $0 |
| MARLA LAFIKES | ||||||||||||||
| PHYSICIAN | $335,460 | $0 | $0 | $0 | $0 | $0 | $11,621 | $0 | $8,527 | $0 | $355,608 | $0 | $0 | $0 |
| KATHERINE BUNTING | ||||||||||||||
| CEO | $313,202 | $0 | $500 | $0 | $0 | $0 | $11,721 | $0 | $2,400 | $0 | $327,823 | $0 | $0 | $0 |
| KORY BLANK | ||||||||||||||
| ORTHOPEDIC SURGEON | $287,529 | $0 | $0 | $0 | $0 | $0 | $28,138 | $0 | $86 | $0 | $315,753 | $0 | $0 | $0 |
| ALEXIS KING | ||||||||||||||
| CRNA | $260,873 | $0 | $250 | $0 | $0 | $0 | $16,154 | $0 | $3,308 | $0 | $280,585 | $0 | $0 | $0 |
| KIMBERLY KING | ||||||||||||||
| CRNA | $251,568 | $0 | $250 | $0 | $0 | $0 | $10,770 | $0 | $0 | $0 | $262,588 | $0 | $0 | $0 |
Schedule L IRS990ScheduleL
Bus Tr Involve Interested Prsn BusTrInvolveInterestedPrsnGrp
Name Of Interested NameOfInterested
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | NICOLE FYIE | PersonNm |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Relationship Description | WIFE OF BOARD MEMBER | RelationshipDescriptionTxt |
| Transaction | $167,188 | TransactionAmt |
| Transaction | EMPLOYED PHYSICIAN | TransactionDesc |
| Sharing Of Revenues | 0 | SharingOfRevenuesInd |
Schedule M IRS990ScheduleM
Securities Publicly Traded SecuritiesPubliclyTradedGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Non Cash Checkbox | Yes (X) | NonCashCheckboxInd |
| Contribution | 2 | ContributionCnt |
| Noncash Contributions Rpt F990 | $3,006,616 | NoncashContributionsRptF990Amt |
| Method Of Determining Revenues | FMV | MethodOfDeterminingRevenuesTxt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Any Property That Must Be Held | 0 | AnyPropertyThatMustBeHeldInd |
| Review Process Unusual NC Gifts | 0 | ReviewProcessUnusualNCGiftsInd |
| Third Parties Used | 0 | ThirdPartiesUsedInd |
Schedule O IRS990ScheduleO
Supplemental Information Detail SupplementalInformationDetail (5 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| 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 BY THE HOSPITAL. |
| 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 15A | 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 OF THE BOARD, 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. |
| 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 1,576,850. MANAGEMENT AND GENERAL EXPENSES 470,944. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,047,794. PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 1,025,881. MANAGEMENT AND GENERAL EXPENSES 306,391. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,332,272. COLLECTION FEES : PROGRAM SERVICE EXPENSES 88,302. MANAGEMENT AND GENERAL EXPENSES 26,372. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 114,674. PHYSICIAN FEES : PROGRAM SERVICE EXPENSES 1,633,698. MANAGEMENT AND GENERAL EXPENSES 487,924. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,121,622. |
Schedule R IRS990ScheduleR
Id Related Tax Exempt Org IdRelatedTaxExemptOrgGrp
Disregarded Entity Name DisregardedEntityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | FAIRFIELD MEMORIAL HOSPITAL FOUNDATION | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 303 NW 11TH ST | AddressLine1Txt |
| City | FAIRFIELD | CityNm |
| State Abbreviation | IL | StateAbbreviationCd |
| ZIP | 62837 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 371185754 | EIN |
| Primary Activities | SUPPORT THE HOSPITAL | PrimaryActivitiesTxt |
| Legal Domicile State | IL | LegalDomicileStateCd |
| Exempt Code Section | 501(C)(3) | ExemptCodeSectionTxt |
| Public Charity Status | LINE 12B, II | PublicCharityStatusTxt |
| Direct Controlling NA | N/A | DirectControllingNACd |
| Controlled Organization | 0 | ControlledOrganizationInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Receipt Of Int Annts Rnts Rylts | 0 | ReceiptOfIntAnntsRntsRyltsInd |
| Gift Grnt Or Cap Contri To Oth Org | 0 | GiftGrntOrCapContriToOthOrgInd |
| Gift Grnt Cap Contri From Oth Org | 0 | GiftGrntCapContriFromOthOrgInd |
| Loans Or Guarantees To Other Org | 0 | LoansOrGuaranteesToOtherOrgInd |
| Loans Or Guarantees From Oth Org | 0 | LoansOrGuaranteesFromOthOrgInd |
| Div Related Organization | 0 | DivRelatedOrganizationInd |
| Asset Sale To Other Org | 0 | AssetSaleToOtherOrgInd |
| Asset Purchase From Other Org | 0 | AssetPurchaseFromOtherOrgInd |
| Asset Exchange | 0 | AssetExchangeInd |
| Rental Of Facilities To Oth Org | 0 | RentalOfFacilitiesToOthOrgInd |
| Rental Of Fclts From Oth Org | 0 | RentalOfFcltsFromOthOrgInd |
| Perform Of Services For Oth Org | 0 | PerformOfServicesForOthOrgInd |
| Perform Of Services By Other Org | 0 | PerformOfServicesByOtherOrgInd |
| Sharing Of Facilities | 0 | SharingOfFacilitiesInd |
| Paid Employees Sharing | 0 | PaidEmployeesSharingInd |
| Reimbursement Paid To Other Org | 0 | ReimbursementPaidToOtherOrgInd |
| Reimbursement Paid By Other Org | 0 | ReimbursementPaidByOtherOrgInd |
| Transfer To Other Org | 0 | TransferToOtherOrgInd |
| Transfer From Other Org | 0 | TransferFromOtherOrgInd |
Comments