2020-02-21T08:30:47-06:00 2019-06-30 430352985 KERBER ECK & BRAECKEL LLP 3401 OFFICE PARK DRIVE MARION IL 62959 990 2018-07-01 370661202 FAIRFIELD MEMORIAL HOSPITAL ASSOC FAIR 6188422611 303 NW 11TH STREET FAIRFIELD IL 62837 KATHERINE BUNTING CEO 6188422611 2020-02-20 1 ANNA GUETERSLOH P01315485 6189938724 2020-02-20 66.220.95.27 2020-02-20 08:47:31 CS P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 34F6E04C7B21FCB7372CFAC9DD4F1540E9B213FD 2018 2020-04-17 16:48:07Z KATHERINE BUNTING 303 NW 11TH STREET FAIRFIELD IL 62837 32587911 0 X WWW.FAIRFIELDMEMORIAL.ORG X 1943 IL THE MISSION OF FAIRFIELD MEMORIAL HOSPITAL IS TO MAINTAIN AND IMPROVE THE HEALTH OF THE COMMUNITIES WE SERVE. 9 7 413 61 0 0 106077 34952 30007433 31311387 163360 100076 1257682 1141496 31534552 32587911 0 0 0 0 16340709 17271959 0 0 0 14367649 14760020 30708358 32031979 826194 555932 24105006 24318933 8054433 7712428 16050573 16606505 X THE MISSION OF FAIRFIELD MEMORIAL HOSPITAL IS TO MAINTAIN AND IMPROVE THE HEALTH OF THE COMMUNITIES WE SERVE. 0 0 27315544 32552959 AS A NOT-FOR-PROFIT COMMUNITY HOSPITAL, FAIRFIELD MEMORIAL HOSPITAL 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 ORGIN, HANDICAP, AGE, OR ABILITY TO PAY. ALTHOUGH REIMBURSEMENT FOR SERVICES RENDERED IS CRITICAL TO THE OPERATION AND STABILITY OF FAIFIELD 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 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. 27315544 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 1 26 0 413 1 0 0 0 0 0 0 0 0 0 0 X 9 7 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 IL X AMY MARSH 6188478260 303 NW 11TH ST FAIRFIELD IL 62837 PATRICK MOLT MD PRESIDENT 1.75 X 57713 0 0 JOSEPH HUNGERFORD VICE PRESIDENT 1.75 X 0 0 0 ANITA POND SECRETARY/TREASURER 1.75 X 0 0 0 CLARK GRIFFITH TRUSTEE 1.25 X 0 0 0 DONNA MASTERSON TRUSTEE 1.25 X 0 0 0 JAMIE POLLARD TRUSTEE 1.25 X 0 0 0 TOBY HUCKER TRUSTEE 1.25 X 0 0 0 JARED VAUGHN TRUSTEE 1.75 X 0 0 0 DOUG WILSON TRUSTEE 1.25 X 0 0 0 KATHERINE BUNTING CEO 40.00 X 273423 0 12226 AMY MARSH CFO 40.00 X 106380 0 6245 TRACY TAYLOR CNO 40.00 X 101483 0 1951 WESLEY THOMPSON PHYSICIAN 40.00 X 418962 0 26908 CHRISTOPHER BALLARD PHYSICIAN 40.00 X 282879 0 27602 ALEXIS KING CRNA 40.00 X 272430 0 12570 NICOLE FYIE PHYSICIAN 40.00 X 244300 0 27541 MARLA LAFIKES PHYSICIAN 40.00 X 256699 0 27277 2014269 0 142320 13 0 1 0 THE HASKELL CO 111 RIVERSIDE AVENUE JACKSONVILLE FL 32202 DESIGN BUILD CONTRACTOR 1277300 DR RODNEY BEELER 2142 KETTLES HILL COURT EVANSVILLE IN 477258266 ER PHYSICIAN 380102 DOUGLAS FRANKEL 407 S MARKET ST MARION IL 62959 ER PHYSICIAN 371532 ANTONIO RODRIGUEZ 4988 N WHITEWATER RD OLNEY IL 62450 ER PHYSICIAN 343139 MICHELLE O'NEILL 10345 WILMINGTON DRIVE EVANSVILLE IN 47577 ER PHYSICIAN 292865 6 34952 34952 NET PATIENT SERVICE REVENUE 31311387 31311387 31311387 100076 100076 244797 0 244797 244797 244797 304B REBATE 352270 352270 CAFETERIA SERVICES 190940 190940 EHR REVENUE 165747 165747 187742 187742 896699 32587911 32552959 0 0 X 501708 501708 13540998 12524161 1016837 120660 107629 13031 2226044 1985186 240858 882549 787234 95315 55202 55202 47300 47300 5228448 4491042 737406 291100 291100 1782467 1544096 238371 1140910 1140910 174163 138010 36153 405865 306351 99514 1459046 1459046 215747 215747 DRUGS 1305519 1305519 BED AND PROVIDER TAX AM 845579 845579 MEDICAL SUPPLIES 737224 737224 REPAIRS AND MAINTENANCE 608018 439674 168344 463432 349462 113970 32031979 27315544 4716435 0 1611 1928 3918888 2674059 4000323 4111807 7044 1027168 1107571 618239 582776 511164 583853 41070883 26569550 13364963 14501333 800 800 654806 754806 24105006 24318933 1644601 1883356 165747 0 5466816 5092506 777269 736566 8054433 7712428 X 15848027 16507527 201977 98409 569 569 16050573 16606505 24105006 24318933 555932 0 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 449428 449428 20568782 11280213 9288569 18269722 15236117 3033605 1782951 53220 1729731 14501333 X 32691479 103568 103568 32587911 0 32587911 32031979 0 32031979 0 32031979 PART X, LINE 2: THERE WERE NO PENALTIES, INTEREST, OR UNCERTAIN TAX BENEFITS IDENTIFIED AND RECORDED AS A LIABILITY. PART XI, LINE 2D - OTHER ADJUSTMENTS: CHANGE IN NET ASSETS WITH DONOR RESTRICTIONS 1 1 1 X 1 X 1 1 0 0 205641 205641 0.00640 6090483 1016576 5073907 0.15840 6296124 1016576 5279548 0.16480 6296124 1016576 5279548 0.16480 1 1014673 253668 15591149 15678164 -87015 X 1 1 1 1 FAIRFIELD MEMORIAL HOSPITAL 303 NW 11TH STREET FAIRFIELD IL 62837 WWW.FAIRFIELDMEMORIAL.ORG 320005545 X X X X FAIRFIELD MEMORIAL HOSPITAL 1 0 0 1 X X X X X X X X X X 16 1 0 0 1 X WWW.FAIRFIELDMEMORIAL.ORG X 1 16 1 WWW.FAIRFIELDMEMORIAL.ORG 0 1 X 200.000000000000 300.000000000000 X X 1 1 X X X X 1 X WWW.FAIRFIELDMEMORIAL.ORG X WWW.FAIRFIELDMEMORIAL.ORG X WWW.FAIRFIELDMEMORIAL.ORG X X X X X X X 1 X 0 X X X X 1 X 0 0 FAIRFIELD MEMORIAL HOSPITAL PART V, SECTION B, LINE 3J: THE MOST RECENT CHNA WAS COMPLETED IN AUGUST 2019. ALL QUESTIONS ARE ANSWERED/UPDATED BASED ON THE CHNA COMPLETED IN 2019 HOWEVER THE YEAR WAS LISTED AS 2016 ON THE SCHEDULE H DUE TO THE TAX FORM BEING A 2018 TAX FORM AND THE FORM WOULD NOT BE ELECTRONICALLY ACCEPTED WITH A CHNA DATE AFTER THE FORM YEAR. 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, INCLUDING THOSE WITH SPECIAL KNOWLEDGE OF, OR EXPERTISE IN PUBLIC HEALTH (LOCAL, REGIONAL, STATE AND/OR TRIBAL). MEMBERS OF MEDICALLY UNDERSERVED, LOW-INCOME, AND MINORITY POPULATIONS SERVED BY THE HOSPITAL OR INDIVIDUALS OR ORGANIZATIONS REPRESENTING THE INTERESTS OF SUCH POPULATIONS ALSO PROVIDED INPUT. 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, OR OTHER BARRIERS. MEMBERS OF THE CHNA STEERING COMMITTEE, THOSE WHO PARTICIPATED IN FOCUS GROUPS AND THE NEEDS IDENTIFICATION AND PRIORITIZATION PROCESS, WERE CHOSEN BASED ON THEIR UNIQUE EXPERTISE AND EXPERIENCE, INFORMED PERSPECTIVES, 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 PUBLIC HEALTH ADMINISTRATOR-A PHARMACIST-A FAMILY PRACTICE PHYSICIAN-A BEHAVIORAL THERAPIST AND OTHERS FAIRFIELD MEMORIAL HOSPITAL PART V, SECTION B, LINE 11: THE FACILITY'S IMPLEMENTATION STRATEGY PRIORITIZED FOUR NEEDS AS FOLLOWS:PRIORITY #1 - REDUCE OBESITY-THE FACILITY WILL EXPLORE PROVIDING COMMUNITY EDUCATION PROGRAMS FROM THE NUTRITIONIST-THE FACILITY WILL EXPLORE YOUTH EDUCATION AND AWARENESS PROGRAMS-THE FACILITY WILL REESTABLISH A WEIGHT LOSS CLINIC-THE FACILITY WILL OFFER COMMUNITY EDUCATION THROUGH SOCIAL MEDIA ABOUT SEDENTARY LIFESTYLES-THE FACILITY WILL OFFER COMMUNITY EDUCATION THROUGH SOCIAL MEDIA ABOUT FAST FOODS AND HEALTHY DIETS-THE FACILITY WILL OFFER COMMUNITY EDUCATION THROUGH SOCIAL MEDIA ABOUT THE IMPORTANCE OF PHYSICAL ACTIVITY AND RECREATION AND WHERE OPPORTUNITIES FOR BOTH CAN BE FOUND IN THE COMMUNITYTHE FACILITY PLANS TO DEDICATE VARIOUS PROGRAMS/RESOURCES TO ADDRESS THESE NEEDS INCLUDING ADMNINSTRATION, A NUTRITIONIST, MARKETING, PHYSICAL THERAPY, PHYSICIAN ASSISTANT AND FUNDS. THE FACILITY WILL COLLABORATE WITH OTHER ORGANIZATIONS - SCHOOLS, PUBLIC HEALTH, PARK DISTRICT, AND GYMS AND OTHER EXERCISE AND RECREATION FACILITIES.PRIORITY #2 - ADDRESS SUBSTANCE ABUSE THROUGH EXPANDED PREVENTION EDUCATION AT YOUNG AGES-THE FACILITY WILL EXPLORE FORMATION OF A SADD PROGRAM OR SIMILAR YOUTH PREVENTION EFFORT WITH HIGH SCHOOL STUDENTS-THE FACILITY WILL COLLARBORATE WITH SCHOOLS TO BRING APPROPRIATE SUBSTANCE ABUSE PREVENTION PROGRAMS TO STUDENTSTHE FACILITY PLANS TO DEDICATE VARIOUS PROGRAMS/RESOURCES TO ADDRESS THESE NEEDS INCLUDING ADMNINSTRATION, BEHAVIORAL HEALTH AND FUNDS. THE FACILITY WILL COLLABORATE WITH OTHER ORGANIZATIONS - SCHOOL ADMINISTRATORS, PERSONS WITH EXPERTISE IN YOUTH ORGANIZING AND PROGRAMMING, LAW ENFORCEMENT, AND PUBLIC HEALTHPRIORITY #3 - EXPANDED ACCESS TO DETOXIFICATION-THE FACILTY WILL EXPLORE THE FEASIBILITY OF LOCAL INPATIENT DETOXIFICATION-THE FACILITY WILL EXPLORE AVAILABLE PARTNERS FOR A DETOXIFICATION CENTER FOR TRANSFERSTHE FACILITY PLANS TO DEDICATE VARIOUS PROGRAMS/RESOURCES TO ADDRESS THESE NEEDS INCLUDING ADMNINSTRATION, PHYSICIANS AND FUNDS. THE FACILITY WILL COLLABORATE WITH OTHER ORGANIZATIONS - REGIONAL PARTNERSPRIORITY #4 - EXPAND LOCAL SERVICES FOR SUICIDE AND OTHER MENTAL HEALTH CRISES-THE FACILITY WILL BUILD A NEW EMERGENCY ROOM WITH TWO DEDICATED PSYCHIATRIC USE ROOMS-THE FACILITY WILL HIRE A CRISIS INTERVENTIONISTTHE FACILITY PLANS TO DEDICATE VARIOUS PROGRAMS/RESOURCES TO ADDRESS THESE NEEDS INCLUDING ADMNINSTRATION, SOCIAL SERVICES, EMERGENCY PHYSICIANS AND FUNDS. THE FACILITY WILL COLLABORATE WITH OTHER ORGANIZATIONS - LAW ENFORCEMENT AND REGIONAL MENTAL HEALTH SERVICESALL NEEDS IDENTIFIED BY THE STEERING GROUP WERE ADDRESSED IN THE IMPLEMENTATION STRATEGY. FAIRFIELD MEMORIAL HOSPITAL PART V, SECTION B, LINE 16J: THE POLICY IS VERBALLY DISCUSSED WITH ALL SELF-PAY PATIENTS. 1 1 - HORIZON HEALTHCARE 213 NW 10TH STREET SUITE 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 LINES 7A AND 7B OF PART I OF SCHEDULE H. PART III, LINE 2: THE HOSPITAL CALCULATED BAD DEBT EXPENSE AT COST USING THE COST TO CHARGE RATIO AS CALCULATED USING WORKSHEET 2 OF 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, LINE9B. 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: NOTE S - UNCOMPENSATED CARE AND COMMUNITY BENEFIT IN SUPPORT OF ITS MISSION, THE HOSPITAL VOLUNTARILY PROVIDES CARE TO PATIENTS AT LESS THAN ITS ESTABLISHED CHARGES FOR PATIENTS THAT MEET THE HOSPITAL'S CHARITY CARE CRITERIA. BECAUSE THE HOSPITAL DOES NOT PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE, THEY ARE NOT REPORTED IN NET PATIENT SERVICES REVENUE. 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 MANY TIMES THE PAYMENTS ARE LESS THAN THE COST OF RENDERING THE SERVICES PROVIDED. THE HOSPITAL'S TOTAL COST OF UNCOMPENSATED CARE RELATING TO THESE SERVICES AND OTHER SERVICES ARE AS FOLLOWS: CHARITY CARE $213,171 STATE MEDICAID AND OTHER PUBLIC PROGRAMS $5,265,955 UNCOLLECTIBLE ACCOUNTS $1,014,673 THE UNCOMPENSATED CARE COST OF STATE MEDICAID AND OTHER PUBLIC AID PROGRAMS IS DETERMINED BY COMPUTING THE COST OF PROVIDING THAT CARE LESS AMOUNTS PAID BY THE PROGRAM. IN ADDITION TO THE ABOVE COST OF UNCOMPENSATED CARE, 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 KNOWLEDGE THAT THEY WILL NOT BE SELF-SUPPORTING OR FINANCIALLY VIABLE. 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 BENEFTIS, 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. PART III, LINE 9B: THE FAIRFIELD MEMORIAL HOSPITAL APPLIES ITS COLLECTION PRACTICES EQUALLY TO ALL PATIENTS, BOTH CHARITY CARE ELIGIBLE AND NON-CHARITY CARE PATIENTS. THE PROCEDURES FOR COLLECTION ON PATIENT ACCOUNTS ARE 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 OUR EARLY-OUT DEPARTMENT FOR A FOLLOW-UP STATEMENT/PHONE CALL TO THE PATIENT. THE HOSPITAL OFFERS THE PATIENTS SEVERAL PAYMENT ALTERNATIVES:1. CASH/CHECK FOR THE FULL AMOUNT2. MASTERCARD/VISA/DISCOVER3. SHORT-TERM MONTHLY INSTALLMENTS BASED ON OUTSTANDING BALANCESPECIAL 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 ARRANGMENTS AS OUTLINED ABOVE ARE NOT MADE, THE ACCOUNT WILL PROCEED THROUGH A COLLECTION PROCESS AS FOLLOWS:DAY 1 - 1ST NOTICE SENTDAY 7-14 - FIRST PHONE CALL IS MADE. AT LEAST ONE PHONE CALL OR NOTICE PER WEEK FOR THE REMAINDER OF THE EARLY-OUT 90 DAY PERIODDAY 75 - DEMAND NOTICE IS SENTDAY 90 - ACCOUNT IS SENT TO COLLECTIONS ANY ACCOUNT THAT IS SENT TO COLLECTIONS MAY BE TURNED OVER TO AN ATTORNEY AND ANY ADDITIONAL COSTS ASSOCIATED WITH COLLECTIONS WILL BE ADDED TO THE ACCOUNT BALANCE. PART VI, LINE 2: GENERALLY SPEAKING, THE DETERMINATION OF CURRENT AND FUTURE HEALTH CARE NEEDS OF THE COMMUNITY OR COMMUNITIES SERVED BY FAIRFIELD MEMORIAL HOSPITAL IS BASED ON ALL OR A COMBINATION OF THE FOLLOWING FACTORS; EXISTENCE OR NONEXISTENCE OF SERVICES, OPPORTUNITY, SUPPLY, DEMONSTRATED NEED, "VOICE OF THE CUSTOMER", AND /OR COLLABORATIVE EFFORTS WITH OUTSIDE ENTITIES, GOVERMENT AGENCIES, AND OTHER HEALTH CARE PROVIDERS THAT WOULD ENABLE THEFILLING OF A NEED OR ENHANCE AND COMPLIMENT AN ALREADY EXISTING SERVICE. DATA IS GATHERED CONSTANTLY THROUGH BENCHMARKETING, MARKET RESEARCH, CUSTOMER SURVEYS, PHYSCIAN 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 STRATEGIC PLANNING PROCESSES. PART VI, LINE 3: SIGNS ARE POSTED IN THE FACILITY. THE PATIENT'S BILL INFORMS THEM OF FINANCIAL ASSISTANCE PROGRAM. OUR HOSPITAL WEBSITE HAS A LINK TO THE FINANCIAL ASSISTANCE APPLICATION. SOCIAL SERVICE DEPARTMENT SPEAKS TO INPATIENTS ABOUT THE PROGRAM. PART VI, LINE 4: FAIRFIELD MEMORIAL HOSPITAL SERVES THE POPULATIONS 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 16,495. THE MEDIAN HOUSEHOLD INCOME IN 2017 WAS $46,405, WHICH WAS 75.8% OF ILLINOIS' AVERAGE. THE PERCENTAGE OF INDIVIDUALS BELOW POVERTY LEVEL WAS 14%. PART VI, LINE 7, REPORTS FILED WITH STATES IL 1 X X X X X 0 0 0 0 0 0 0 0 0 KATHERINE BUNTING CEO 273423 0 0 0 0 0 4992 0 7234 0 285649 0 0 0 WESLEY THOMPSON PHYSICIAN 418962 0 0 0 0 0 5542 0 21366 0 445870 0 0 0 CHRISTOPHER BALLARD PHYSICIAN 282879 0 0 0 0 0 5400 0 22202 0 310481 0 0 0 ALEXIS KING CRNA 272430 0 0 0 0 0 5336 0 7234 0 285000 0 0 0 NICOLE FYIE PHYSICIAN 206403 0 0 0 37897 0 2484 0 25057 0 271841 0 0 0 MARLA LAFIKES PHYSICIAN 256699 0 0 0 0 0 5075 0 22202 0 283976 0 0 0 PATRICK MOLT PHYSICIAN 57713 BOARD MEMBER 0 NICOLE FYIE PHYSICIAN 271841 WIFE OF BOARD MEMEBER 0 POLLARD REALTY FAMILY RELATIONSHIP WITH BOARD MEMBER 50000 REAL ESTATE TRANSACTION - AGENT TO HOSPITAL 0 FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 WAS REVIEWED BY THE CFO AND FINANCE COMMITTEE. AFTER THE FINANCE COMMITTEE APPROVAL, IT WAS TAKEN TO THE FULL BOARD FOR APPROVAL. FORM 990, PART VI, SECTION B, LINE 12C ANNUALLY EACH BOARD MEMBER RECEIVES THE CORPORATE COMPLIANCE POLICY WHICH INCLUDES THE CONFLICT OF INTEREST POLICY WITHIN IT TO REVIEW AND SIGN THAT THEY HAVE READ THE POLICY AND HAVE NO CONFLICTS. ALL SIGNED DOCUMENTS ARE KEPT ON FILE IN ADMINISTRATION OFFICE. FORM 990, PART VI, SECTION B, LINE 15 THE PROCESS TO DETERMINE COMPENSATION FOR THE CEO WAS AS FOLLOWS THROUGH 2018. THE CEO'S COMPENSATION PROCESS INVOLVES ALLIANT, THE HOSPITAL'S MANAGEMENT COMPANY, BRINGING EVALUATION TIME SALARY INFORMATION FOR OTHER ALLIANT HOSPITALS WHICH INCLUDE HOSPITAL'S IN THE FOLLOWING STATES: ILLINOIS, KENTUCKY, AND INDIANIA; AS WELL AS SALARY INFORMATION FOR CEO'S FROM OTHER HOSPITAL'S IN RELEVANT SIZE (IN REVENUES) TO FMH. THE SALARY COMPARISON INFORMATION IS PRESENTED TO THE PERSONNEL COMMITTEE OF THE BOARD IN WHICH THEY REVIEW THE INFORMATION AND ESTABLISH THE RATE FOR THE CEO. MARKET WAGE DATA FOR THE HEALTHCARE INDUSTRY IS REVIEWED FOR COMPARABLERATES FROM THREE SALARY SURVEYS INCLUDING ALLIANT AS ONE. THE CEO DETERMINES THE AMOUNTS FOR THE OFFICERS. BEGINNING IN 2019, THE PROCESS TO DETERMINE COMPENSATION FOR THE CEO IS AS FOLLOWS: SEVERAL MARKET REPORTS ARE COMPILED AND REVIEWED, INCLUDING BECKERS HOSPITAL REVIEW, CEO COMPENSATION REPORT. THE CFO REQUESTED AND WAS PROVIDED DATA FROM THE AUDIT FIRM WHO PROVIDED AN ANALYSIS OF CEO COMPENSATION BY SIZE OF HOSPITAL, FOR NUMEROUS HOSPITALS IN THE 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 OF DIRECTORS, WHO REVIEWED THE DOCUMENTS, AND ESTABLISHED A RATE FOR THE CEO. THE COMPENSATION COMMITTEE PRESENTED THE RECOMMENDED RATE TO THE FULL BOARD OF DIRECTORS FOR DISCUSSION AND APPROVAL. FORM 990, PART VI, SECTION C, LINE 19 COPIES OF THE ORGANIZATIONS GOVERING DOCUMENTS, CONFLICT OF INTEREST POLICIES, FINANCIAL STATEMENTS, AND THE FEDERAL FORM 990 TAX RETURN ARE AVAILABLE UPON REQUEST FROM THE ADMINISTRATIVE OFFICES. FORM 990, PART IX, LINE 11G PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 2,715,551. MANAGEMENT AND GENERAL EXPENSES 737,406. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 3,452,957. PHYSICIANS FEES: PROGRAM SERVICE EXPENSES 1,775,491. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,775,491. FAIRFIELD MEMORIAL HOSPITAL FOUNDATION 303 NW 11TH STREET FAIRFIELD IL 62837 371185754 SUPPORT IL 501C3 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