2016-08-05T13:43:09-05:00 2015-09-30 420714325 RSM US LLP 1 SOUTH WACKER SUITE 800 CHICAGO IL 60606 990 2014-10-01 370661230 PASSAVANT MEMORIAL AREA HOSPITAL ASN PASS 2172459541 1600 WEST WALNUT STREET JACKSONVILLE IL 62650 DAVID A BOLEN VICE PRESIDENT & CFO 2172459541 2016-08-05 1 ZACHARY A FORTSCH P00052725 3126343400 2014 2016-12-15 16:53:06Z DAVID A BOLEN 1600 WEST WALNUT STREET JACKSONVILLE IL 62650 127128962 0 X WWW.PASSAVANTHOSPITAL.COM X 1906 IL OUR MISSION IS TO PROVIDE EXCELLENT CARE WITH COMPASSION AND COMMITMENT. 18 15 988 171 618973 41039 1625310 972468 82376378 91550703 5385776 3203683 1719947 1691440 91107411 97418294 61648 32772 0 0 45140378 46789290 0 0 0 35037651 34110414 80239677 80932476 10867734 16485818 174435302 156520865 50958367 50257417 123476935 106263448 X OUR MISSION IS TO PROVIDE EXCELLENT CARE WITH COMPASSION AND COMMITMENT. 0 0 6724701 17044433 SURGERYTHE SURGICAL DEPARTMENT AT PASSAVANT AREA HOSPITAL IS A STATE OF THE ART COMBINE SURGICAL AREA THAT SERVICES INPATIENT AND OUTPATIENT CASE VOLUME. THE CASE VOLUME FOR THE SURGICAL DEPARTMENT IS APPROXIMATELY 6000 CASES PER YEAR WHICH INCLUDES A VOLUME OF APPROXIMATELY 2200 UPPER AND LOWER GASTROINTESTINAL SCOPES. THE UNIT HAS 7 MULTISPECIALTY SURGICAL SUITES, 1 OBSTETRICAL SURGICAL SUITE, AND 2 DEDICATED GI SUITES. THE SCOPE OF THE SURGICAL PROCEDURES PROVIDED IN THE DEPARTMENT INCLUDES GENERAL, ORTHOPEDIC, UROLOGY, EAR, NOSE AND THROAT, OPHTHALMOLOGY, AND GYNECOLOGY. EIGHTY PERCENT OF THE CASE VOLUME IN THE SURGICAL DEPARTMENT IS AMBULATORY SURGICAL PROCEDURES. THE DEPARTMENT'S HOURS OF OPERATION ARE FROM 7:00 A.M. TO 5:00 P.M. MONDAY THRU FRIDAY. THE DEPARTMENT PROVIDES ON CALL COVERAGE AFTER HOURS ON WEEKDAYS, WEEKENDS AND HOLIDAYS. THE ON CALL STAFF IS AVAILABLE TO RESPOND TO EMERGENCY CASE AND BEGIN THE CASE WITHIN 20 MINUTES OF THE DECISION TO PERFORM THE OPERATION. THE SURGICAL DEPARTMENT IS SUPPORTED BY A 23 BED AMBULATORY SURGERY SUITE LOCATED ADJACENT TO THE SURGERY DEPARTMENT WHICH PROVIDES PRE ADMISSION ASSESSMENT AND PRE-OPERATIVE TEACHING, PHASE II POST-OPERATIVE CARE, AND COMPREHENSIVE POST-OPERATIVE DISCHARGE TEACHING. PHASE I POST-OPERATIVE CARE IS PROVIDED IN THE POST ANESTHESIA CARE UNIT LOCATED WITHIN THE SURGICAL DEPARTMENT. 4565091 10382942 LABORATORYTHE DEPARTMENT OF LABORATORY MEDICINE AT PASSAVANT HOSPITAL IS DEDICATED TO THE PROVISION OF INDIVIDUALIZED, EFFICIENT, AND HIGH QUALITY CARE TO ALL PATIENTS. LABORATORY PROCESSES INCLUDES THE COLLECTION, MONITORING, AND EVALUATION OF IMPORTANT ASPECTS OF CARE: SPECIMEN COLLECTION, SPECIMEN EVALUATION (TESTING), LABORATORY VALUES REPORTING AND ANATOMICAL PATHOLOGY SERVICES. APPROXIMATELY 500 VARIOUS TEST PROCEDURES OR COMBINATIONS OF TEST PROCEDURES ARE PERFORMED IN THE CLINICAL LABORATORY. ANY PROCEDURE NOT PERFORMED ON SITE IS REFERRED TO AN ACCREDITED REFERENCE LABORATORY. DURING FISCAL YEAR 2015, PASSAVANT HOSPITAL LABORATORY REPORTED 323,965 TESTS.PASSAVANT HOSPITAL LABORATORY PERFORMS TESTS IN THE FOLLOWING FIELDS: BLOOD BANK, CHEMISTRY, COAGULATION, CYTOLOGY, HEMATOLOGY, HISTOPATHOLOGY, MICROBIOLOGY, SEROLOGY, AND URINALYSIS. THE LABORATORY DIRECTOR PROVIDES CONSULTATIONS REGARDING THE ORDERING OF APPROPRIATE TESTS AND THE MEDICAL SIGNIFICANCE OF THE LABORATORY DATA REPORTED. THE LABORATORY IS EQUIPPED WITH THE LATEST INSTRUMENTATION AND TECHNOLOGIES TO ASSIST IN THE ANALYSIS OF BODY FLUIDS, CELLS AND TISSUE.PATIENTS ARE SERVED ON BOTH AN INPATIENT AND OUTPATIENT BASIS. ADDITIONALLY, SPECIMENS ARE DELIVERED OR PICKED UP FROM PHYSICIAN'S OFFICES AND NURSING HOMES. IN FISCAL YEAR 2015, THERE WERE 106,007 INPATIENT TESTS, 217,958 OUTPATIENT TESTS AND 23,090 TESTS FROM OFFICES AND NURSING HOMES.THE PASSAVANT HOSPITAL LABORATORY ALSO PARTICIPATES IN TESTING SPECIMENS FOR THE KIDNEY MOBILE DURING THEIR ONCE A YEAR ONSITE VISIT. THE LABORATORY TESTS SPECIMENS FROM THE FECAL BLOOD SCREENING PROGRAM FOR THE DETECTION OF CANCER HOSTED BY THE MIA WARE FOUNDATION. ANY TESTS ORDERED BY PHYSICIANS STAFFING A COMMUNITY BENEFIT SERVICE AREA WERE OBTAINED AND PROCESSED BY THE LABORATORY. 4496176 6273475 EMERGENCY SERVICESTHE EMERGENCY DEPARTMENT AT PASSAVANT AREA HOSPITAL CONSISTS OF 22 BEDS, PROVIDING EMERGENCY MEDICAL CARE AND TREATMENT 24/7 TO PATIENTS FROM SURROUNDING COMMUNITIES. PATIENT VOLUME FOR FISCAL YEAR 2015 WAS 28,989 PATIENTS. DESIGN OF THE ED INCLUDES TRIAGE, ED FAST TRACK, TWO CRITICAL CARE BAYS, BOTH EQUIPPED WITH IMAGING, ONE SECURITY ROOM, TWO PROCEDURE ROOMS, TWO NEGATIVE AIR ISOLATION ROOMS, EMS COMMUNICATION ROOM, AND DECONTAMINATION AREA. EMERGENCY RESUSCITATIVE EQUIPMENT IS LOCATED IN KEY AREAS TO SUPPORT THE CARE PROVIDED.PATIENTS PRESENT WITH A WIDE RANGE OF SYMPTOMS AND VARYING LEVELS OF ACUITY. PATIENT PLACEMENT OCCURS THROUGH UTILIZATION OF THE ESI LEVEL SYSTEM. TRACKING OF PATIENTS OCCURS THROUGH THE EDIS TRACKING BOARD. CARE PROVIDERS INCLUDE BOTH ERP'S AND APN'S, WITH NURSING CARE PROVIDED BY ED RN'S, LPN'S, AND TECHNICIANS. CARE AND TREATMENT IS PROVIDED FOR A VARIETY OF SYMPTOMS INDICATIVE OF MEDICAL AND / OR SURGICAL CONDITIONS REQUIRING URGENT OR EMERGENT INTERVENTION INCLUDING BUT NOT LIMITED TO: AMI, CARDIAC ARRHYTHMIAS, CHF, ACUTE EXACERBATION COPD, CARDIO-RESPIRATORY ARREST, RESPIRATORY FAILURE, ABDOMINAL PAIN, ACUTE BOWEL OBSTRUCTION, UTI, URINARY DISORDERS, DIABETES, SEPSIS, INFECTIOUS DISEASES, DECLARED TRAUMA, MENTAL HEALTH DISORDERS, SORE THROAT, EAR INFECTIONS, DENTAL, EENT, ORTHOPEDIC INJURIES, ETC. PAH'S EMERGENCY DEPARTMENT SERVES IN THE FOLLOWING CAPACITIES:REGIONAL SANE CENTER FOR REGION 3EDAP, "EMERGENCY DEPARTMENT APPROVED FOR PEDIATRICS"STAT HEARTEMERGENT STROKE CENTER (DESIGNATED JANUARY 2015) 48749352 32772 57849853 PASSAVANT PROVIDES HEALTHCARE SERVICES TO THE RESIDENTS OF MORGAN, CASS, SCOTT, AND PARTS OF BROWN, GREENE, MACOUPIN, AND PIKE COUNTIES IN WEST CENTRAL ILLINOIS. IN FISCAL YEAR 2015, PASSAVANT PERFORMED 89,541 OUTPATIENT PROCEDURES AND HAD 3,022 INPATIENT ADMISSIONS. ADDITIONALLY, PASSAVANT PROVIDED $3.8 MILLION IN CHARITY CARE. PASSAVANT ALSO PROVIDED ACLS PARAMEDIC SERVICE AND SUPPORT TO THE OUTLYING BLS AMBULANCE PROVIDERS IN THE SURROUNDING COMMUNITIES, AND PROVIDES FREE HEALTH SCREENINGS TO THE VULNERABLE POPULATION, FREE EDUCATION PROGRAMS AND INSURANCE CONSULTATION AT NO CHARGE TO THE COMMUNITY AT LARGE. 48749352 32772 57849853 64535320 1 1 0 1 0 0 0 0 0 1 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 1 1 0 0 1 83 0 1 988 1 1 1 0 0 0 0 0 0 0 0 0 X 18 15 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 IL X DAVID A BOLEN 2172459541 1600 WEST WALNUT STREET JACKSONVILLE IL 62650 KEITH BRADBURY BOARD MEMBER 0.70 0.70 X 0 0 0 DON HEADEN BOARD MEMBER 0.70 0.70 X 0 0 0 JAMES HINCHEN MD BOARD MEMBER 0.70 X 0 0 0 GILBERT JOEHL BOARD MEMBER 0.70 0.70 X 0 0 0 PHYLLIS LAPE PHD BOARD MEMBER 0.70 X 0 0 0 ERIC GIEBELHAUSEN MD BOARD MEMBER 0.70 X 0 0 0 DOUG AWE BOARD MEMBER 0.70 X 0 0 0 STEVEN LILLPOP MD BOARD MEMBER 0.70 50.00 X 0 596758 244991 NANCY SPANGENBERG BOARD MEMBER 0.70 X 0 0 0 KELLY STAAKE BOARD MEMBER 0.70 X 0 0 0 GINNY FANNING BOARD MEMBER 0.70 0.70 X 0 0 0 GREG LEPPER BOARD MEMBER/CHAIRMAN (EFF JAN 15) 0.70 0.70 X 0 0 0 BABU ELADASARI MD BOARD MEMBER (EFF JAN 15) 0.70 50.00 X 0 304782 33264 CHARLES SHEAFF MD BOARD MEMBER (THRU DEC 14) 0.70 50.00 X 0 374976 26734 TOM VEITH TREASURER (EFF JAN 15) 0.70 0.70 X X 0 0 0 JAN TERRY CHAIRMAN (THRU DEC 14)/BOARD MEMBER (EFF JAN 15) 0.70 1.40 X X 0 0 0 GARY SCOTT SECRETARY 0.70 1.40 X X 0 0 0 REGINALD BENTON VICE CHAIRMAN (EFF JAN 15)/TREASURER (THRU DEC 14) 0.70 1.40 X X 0 0 0 DOUGLAS RAHN DBA PRESIDENT & CEO 55.00 5.00 X X 0 672165 291895 DAVID BOLEN VICE PRESIDENT & CFO 55.00 5.00 X 202737 0 27496 MARK RUFF STAFF ANESTHETIST 50.00 X 302182 0 55923 DAVID TONRY STAFF ANESTHETIST 50.00 X 275373 0 51880 MICHAEL DUNSETH STAFF ANESTHETIST 50.00 X 261061 0 40322 JON GREGORY STAFF ANESTHETIST 50.00 X 252655 0 51906 RANDALL MOORE DIRECTOR PERIOPERATIVE SERVICES 50.00 X 244305 0 51731 CHESTER WYNN PRESIDENT & CEO 55.00 5.00 X 118576 0 11518 1656889 1948681 887660 28 1 1 0 AEF MANAGEMENT 1800 E LAKESHORE DRIVE DECATUR IL 62521 ANESTHESIOLOGIST SERVICES 871045 JOHN C DAILEY MDSC 1572 CONCORD RD JACKSONVILLE IL 62650 PHYSICIAN SERVICES 594050 PROSKAUER ROSE LLP ELEVENT TIMES SQUARE NEW YORK NY 10036 LEGAL SERVICES 504258 COGENT HEALTHCARE OF IL LLC 1005 BROADWAY ST QUINCY IL 62301 HOSPITALIST SERVICES 463579 SPI HEALTHCARE 2960 PROFESSIONAL DRIVE SPRINGFIELD IL 62703 PHYSICIAN BILLING SERVICES 397993 6 7954 950743 13771 972468 PATIENT SERVICE REV 621110 91550703 91550703 91550703 1483851 1483851 352305 23814 328491 328491 328491 31406686 29676573 10281 1730113 -10281 1719832 1719832 CAFETERIA 722100 529989 529989 REFERENCE LAB 621500 479991 479991 LIFELINE 812900 138982 138982 213987 213987 1362949 97418294 91550703 618973 4276150 32772 32772 2412726 1930181 482545 31819535 25455628 6363907 1582611 1266089 316522 8458279 6766623 1691656 2516139 2012911 503228 225441 225441 46078 46078 5129521 4103617 1025904 204344 163475 40869 1740134 1392107 348027 402404 321923 80481 1271639 1017311 254328 96017 76814 19203 1414095 1131276 282819 2722407 2177926 544481 1144869 915895 228974 MEDICAL SUPPLIES 6436115 5148892 1287223 REPAIRS AND MAINTENANCE 3193666 2554933 638733 PHARMACEUTICAL SUPPLIES 2930608 2344486 586122 ILLINOIS PROVIDER TAX 2141651 1713321 428330 5011425 4009140 1002285 80932476 64535320 16397156 0 16482 13773 5179633 4459934 12243646 13119245 31210705 766180 1340387 1458610 1173428 29336230 4548103 18392806 24788127 65434008 65038775 39733232 46587196 174435302 156520865 16423463 10843777 26075000 25035000 2156171 2199871 6303733 12178769 50958367 50257417 X 99492057 81798905 553203 1445746 23431675 23018797 123476935 106263448 174435302 156520865 X 16485818 -203780 -33495525 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 30004 0 0 0 30004 0 PART II-B, LINE 1: 39% OF ILLINOIS HOSPITAL ASSOCIATION MEMBERSHIP DUES ARE ALLOCABLE TO LOBBYING ACTIVITIES. 53399234 692 -335081 226482 52838363 75538797 35000 3627985 25580104 222444 53399234 68447459 7579029 487691 75538797 58899464 10026577 478582 68447459 58790267 1821901 1712704 58899464 0.93600 0.05400 0.01000 0 1 1 604700 604700 15267356 2105205 13162151 8750870 2384576 6366294 4713304 58322 4654982 24788127 MALPRACTICE RECEIVABLE 3775712 BENEFICIAL INTEREST IN TRUSTS 19776398 FARMLAND 16818584 PHYSICIAN LOANS 263938 INTEREST IN NET ASSETS OF PAHF 5071946 MEANINGFUL USE RECEIVABLE 863448 MEDICARE SETTLEMENT 17170 46587196 ACCRUED PROFESSIONAL LIABILITY 4796883 HEALTH INSURANCE RETIREE 592011 CHARITABLE GIFT ANNUITIES 126837 MARKET VALUE OF SWAPS 2625492 DUE TO AFFILIATES 21873 PAYABLE TO THIRD PARTY PAYORS-BLUE CROSS 3685487 DEFERRED COMPENSATION AND BENEFITS 330186 12178769 X PART V, LINE 4: PAH'S ENDOWMENT CONSISTS OF 10 DONOR-RESTRICTED FUNDS WITH INCOME TO BE USED FOR CAPITAL PURCHASES, OPERATIONS, SCHOLARSHIPS, AND INDIGENT CARE. PART X, LINE 2: THE AUTHORITATIVE GUIDANCE IN ASC 740, INCOME TAXES, CREATES A SINGLE MODEL TO ADDRESS UNCERTAINTY IN TAX POSITIONS AND CLARIFIES THE ACCOUNTING FOR INCOME TAXES BY PRESCRIBING THE MINIMUM RECOGNITION THRESHOLD A TAX POSITION IS REQUIRED TO MEET BEFORE BEING RECOGNIZED IN THE FINANCIAL STATEMENTS. UNDER THE REQUIREMENTS OF THIS GUIDANCE, TAX-EXEMPT ORGANIZATIONS COULD BE REQUIRED TO RECORD AN OBLIGATION AS THE RESULT OF A TAX POSITION THEY HAVE HISTORICALLY TAKEN ON VARIOUS TAX EXPOSURE ITEMS. EACH OF MHS'S SUBSIDIARIES, EXCLUDING THOSE DESCRIBED IN THE FOLLOWING PARAGRAPH, IS A SEPARATELY INCORPORATED NOT-FOR-PROFIT CORPORATION AS DESCRIBED UNDER SECTION 501(C)(3) OF THE CODE AND IS TAX-EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. THEY DO, HOWEVER, OPERATE CERTAIN PROGRAMS THAT MAY RESULT IN UNRELATED BUSINESS INCOME. UPON REVIEW AS REQUIRED BY ASC 740, INCOME TAX NO TAX PROVISION WAS RECORDED FOR THE YEARS ENDED SEPTEMBER 30, 2015 OR 2014. MP AND MHP ARE CONSIDERED DISREGARDED ENTITIES FOR TAX PURPOSES AND ARE EXEMPT FROM INCOME TAX. MHSCI IS A TAXABLE FOR-PROFIT CORPORATION AND PPA IS A TAXABLE NOT-FOR-PROFIT CORPORATION. BOTH ARE SUBJECT TO FEDERAL AND STATE INCOME TAXES. 1 1 1 X 300.000000000000 1 X 301.000000000000 1 1 0 1 1 3124189 3124189 0.04030 16328743 14404738 1924005 0.02480 19452932 14404738 5048194 0.06510 199013 199013 0.00260 74999 74999 0.00100 67177 67177 0.00090 341189 341189 0.00450 19794121 14404738 5389383 0.06960 1396 1396 0.00000 1396 1396 1 867837 23951964 22503617 1448347 X 1 1 1 1 PASSAVANT MEMORIAL AREA HOSPITAL ASSOC 1600 WEST WALNUT STREET JACKSONVILLE IL 62650 WWW.PASSAVANTHOSPITAL.COM HF107104 X X X PASSAVANT MEMORIAL AREA HOSPITAL ASSOC 1 0 1 1 X X X X X X X X X 14 1 0 1 1 X WWW.PASSAVANTHOSPITAL.COM X 1 14 1 WWW.PASSAVANTHOSPITAL.COM 0 0 1 X 300.000000000000 X X X X 1 1 X X X 1 X WWW.PASSAVANTHOSPITAL.COM X WWW.PASSAVANTHOSPITAL.COM X WWW.PASSAVANTHOSPITAL.COM X X X X X X 1 0 X X X 1 X 0 0 PASSAVANT MEMORIAL AREA HOSPITAL ASSOC PART V, SECTION B, LINE 5: DURING THE CHNA PROCESS, WE MET AND RECEIVED INPUT FROM MANY INDIVIDUALS/ORGANIZATIONS IN OUR COMMUNITY WHO HAVE KNOWLEDGE AND EXPERTISE IN THE AREAS OF OUR IDENTIFIED NEEDS. WE COLLABORATED WITH PUBLIC HEALTH, PROBATION, LAW ENFORCEMENT, SUBSTANCE ABUSE COUNSELORS, COLLEGE HEALTH OFFICIALS, HIGH SCHOOL ADMINISTRATORS, AND NURSES, TEENS, AND OUR OWN HOSPITAL PERSONNEL. PASSAVANT MEMORIAL AREA HOSPITAL ASSOC PART V, SECTION B, LINE 6B: PAH COLLABORATED WITH 12 COMMUNITY ORGANIZATIONS. THEY WERE: MORGAN COUNTY HEALTH DEPARTMENT, ILLINOIS SCHOOL FOR THE DEAF, ILLINOIS SCHOOL FOR THE VISUALLY IMPAIRED, JACKSONVILLE SCHOOL DISTRICT #117, THE WELLS CENTER, PRAIRIELAND UNITED WAY, HEAD START, MENTAL HEALTH CENTERS OF CENTRAL ILLINOIS, MACMURRAY COLLEGE, ILLINOIS COLLEGE, LINCOLN LAND COMMUNITY COLLEGE, AND JACKSONVILLE AREA CENTER FOR INDEPENDENT LIVING. PASSAVANT MEMORIAL AREA HOSPITAL ASSOC PART V, SECTION B, LINE 2: IN APRIL 2014, PASSAVANT AREA HOSPITAL (PAH) BECAME AN AFFILIATE OF MEMORIAL HEALTH SYSTEM (MHS) OF SPRINGFIELD, IL. THE TRANSACTION WAS ACCOUNTED FOR AS AN ACQUISITION, AND ACQUIRED ASSETS AND LIABILITIES WERE RECORDED AT FAIR VALUE. PAH AND MHS HAVE THE SAME FISCAL YEAR OF OCTOBER 1 - SEPTEMBER 30. PAH AND MHS ALSO SHARE A MISSION OF PROVIDING THE HIGHEST QUALITY HEALTH CARE SERVICES TO THE COMMUNITIES EACH SERVES IN CENTRAL ILLINOIS. AFFILIATION WILL RESULT IN ALL PARTIES BEING IN THE BEST POSITION TO CONTINUE AND STRENGTHEN THE HIGH-QUALITY HEALTH CARE SERVICES EACH DELIVERS, AND TO MEET THE CLINICAL, FINANCIAL, AND TECHNOLOGICAL DEMANDS OF DELIVERING HEALTH CARE IN CENTRAL ILLINOIS, BY EXPLORING INITIATIVES THAT ENHANCE THE MISSIONS AND CLINICAL, OPERATIONAL, MANAGEMENT, AND FINANCIAL STRENGTHS OF EACH PARTY. PASSAVANT MEMORIAL AREA HOSPITAL ASSOC PART V, SECTION B, LINE 11: IN REVIEW OF THE SURVEY DATA, 9 PRIORITIES WERE IDENTIFIED. THEY WERE: ACCESS TO CARE, MENTAL HEALTH, EARLY SEXUAL ACTIVITY/TEEN PREGNANCY, OBESITY, DENTAL CARE, SUBSTANCE MISUSE, COLON CANCER, SEXUALLY TRANSMITTED DISEASES, AND TOBACCO. ACCESS TO CARE, MENTAL HEALTH, AND OBESITY WERE CHOSEN AS THE FINAL PRIORITIES. MENTAL HEALTH WAS IDENTIFIED AS THE TOP PRIORITY. THE HOSPITAL WILL OPEN A 10-BED INPATIENT PSYCHIATRIC UNIT. THIS WILL INCREASE THE AVAILABILITY OF LOCAL PSYCHIATRIC SERVICES, REDUCING LONG DRIVES TO OTHER COMMUNITIES AND REDUCE LONG WAIT TIMES FOR THE NUMBER OF AVAILABLE PSYCHIATRIC BEDS. THE HOSPITAL WILL ALSO SUPPORT COMMUNITY EFFORTS TO REDUCE THE STIGMA OF MENTAL HEALTH AND IMPROVE UNDERSTANDING OF REFERRALS TO AVAILABLE COMMUNITY RESOURCES. OBESITY WAS IDENTIFIED AS A HIGH PRIORITY. MEMORIAL AND PASSAVANT WILL WORK TOGETHER TO DEVELOP A STRATEGY TO IMPLEMENT THE MEMORIAL WEIGHT LOSS AND WELLNESS CENTER PROGRAM AT PASSAVANT, IN ORDER TO EXPAND ACCESS TO THE PROGRAM INTO MORGAN COUNTY. THE HOSPITAL WILL WORK TO IMPROVE ATTITUDES ABOUT HEALTHY LIFESTYLES THROUGH MONTHLY EDUCATION PROGRAMS AND A HEALTH AWARENESS MARKETING CAMPAIGN FOR SELECTED SAMPLE GROUPS COVERING A WIDE RANGE OF AGE RANGES AND INCOMES. IN ADDITION, THE HOSPITAL WILL FINANCIALLY SUPPORT PROGRAMS THAT PROVIDE OPPORTUNITIES FOR RESIDENTS TO PRACTICE HEALTHY BEHAVIORS.ACCESS TO CARE WAS IDENTIFIED AS A TOP PRIORITY. PASSAVANT, IN COLLABORATION WITH THE MORGAN COUNTY HEALTH DEPARTMENT AND SOUTHERN ILLINOIS UNIVERSITY SCHOOL OF MEDICINE WILL SECURE APPROVAL FOR AND OPEN A FEDERALLY QUALIFIED HEALTH CENTER (FQHC). PASSAVANT WILL PROVIDE LEADERSHIP AND FINANCIAL SUPPORT TOWARDS THE EFFORT TO ESTABLISH A FQHC IN MORGAN COUNTY. IN ADDITION, THE HOSPITAL WILL FINANCIALLY SUPPORT THE REOPENING AND OPERATIONS OF A WALK-IN STD CLINIC RUN BY THE MORGAN COUNTY HEALTH DEPARTMENT, WHICH WAS CLOSED IN 2008. WITHOUT PASSAVANT'S SUPPORT, THE CLINIC WOULD NOT BE ABLE TO OFFER SERVICES.ACCESS TO DENTAL CARE WAS NOT CHOSEN BECAUSE THE HOSPITAL DOES NOT HAVE THE EXPERTISE TO ADDRESS THE ISSUE. COLON CANCER WAS NOT CHOSEN BECAUSE IT CONSISTENTLY RANKED AS A LOW PRIORITY AMONG COMMUNITY MEMBERS. THE HOSPITAL CURRENTLY OFFERS ADVANCED COLONOSCOPY SERVICES, ANNUAL COLORECTAL CANCER EDUCATION FOR THE COMMUNITY, AND PARTNERS WITH A LOCAL CANCER FOUNDATION TO PROVIDE FREE COLORECTAL SCREENINGS TO COMMUNITY MEMBERS EACH YEAR. SUBSTANCE MISUSE WAS NOT CHOSEN BECAUSE IT DID NOT RANK AS A HIGH PRIORITY AMONG THE ADVISORY COMMITTEE, IN THE COMMUNITY FORUM, OR ON THE SURVEY. IT WAS PERCEIVED BY THE ADVISORY COMMITTEE THAT THERE WOULD BE LITTLE OPPORTUNITY TO MAKE ADDITIONAL IMPACT BEYOND WHAT IS BEING DONE THROUGH THE PARTNERSHIP FOR A HEALTHY COMMUNITY, WHICH IS A COLLABORATION OF LOCAL LAW ENFORCEMENT, EDUCATION INSTITUTIONS, HEALTH PROVIDERS, AND THE WELLS CENTER - A DRUG AND ALCOHOL TREATMENT FACILITY. EARLY SEXUAL ACTIVITY/TEEN PREGNANCY WAS NOT CHOSEN BECAUSE THE MORGAN COUNTY HEALTH DEPARTMENT IS ALREADY ADDRESSING THIS DISPARITY IN THE SCHOOLS, AND IT WOULD BE A DUPLICATION OF SERVICES. TOBACCO RANKED SIGNIFICANTLY LOWER THAN OTHER PRIORITIES IN THE FORUM AND THE SURVEY. IT WAS COMMUNICATED THAT IT WOULD BE DIFFICULT TO MAKE A SIGNIFICANT IMPACT AS THE MORGAN COUNTY HEALTH DEPARTMENT IS PARTNERING WITH THE ILLINOIS QUITLINE TO OFFER SMOKING CESSATION PRODUCTS. SEXUALLY TRANSMITTED DISEASES WILL BE ADDRESSED AS AN ACCESS TO CARE INITIATIVE IN PARTNERSHIP WITH THE HEALTH DEPARTMENT, RATHER THAN A STAND-ALONE PRIORITY. THE HOSPITAL WILL CONTINUE TO SUPPORT THE HEALTH DEPARTMENT'S STD CLINIC WHICH WAS REOPENED IN 2014 USING FUNDS ALLOCATED BY THE HOSPITAL. THIS NEED CONTINUES TO BE MET THROUGH THIS PARTNERSHIP ESTABLISHED AS A RESULT OF THE 2012 CHNA. PASSAVANT MEMORIAL AREA HOSPITAL ASSOC PART V, SECTION B, LINE 13B: PASSAVANT AREA HOSPITAL USES AN AMOUNT UP TO 300% OF THE FPG AS A FACTOR IN DETERMINING ELIGIBILITY FOR PROVING DISCOUNTED CARE. PASSAVANT MEMORIAL AREA HOSPITAL ASSOC PART V, SECTION B, LINE 16I: ALL BILLING STATEMENTS TO THE PATIENTS INDICATE OUR FINANCIAL ASSISTANCE CONTACT INFORMATION. INFORMATION IS ALSO LISTED ON THE CONSENT TREATMENT FORM. PASSAVANT MEMORIAL AREA HOSPITAL ASSOC PART V, SECTION B, LINE 22D: AMOUNT PROVIDED BY THE ATTORNEY GENERAL STATE OF ILLINOIS HOSPITAL UNINSURED PATIENT DISCOUNT ACT. PART V, SECTION B, LINE 16 FINANCIAL ASSISTANCE POLICY WEBSITE AVAILABILITY PASSAVANT MEMORIAL AREA HOSPITAL ASSOC PART V, SECTION B, LINE 16A WEBSITE: WWW.PASSAVANTHOSPITAL.COM PASSAVANT MEMORIAL AREA HOSPITAL ASSOC PART V, SECTION B, LINE 16B WEBSITE: WWW.PASSAVANTHOSPITAL.COM PASSAVANT MEMORIAL AREA HOSPITAL ASSOC PART V, SECTION B, LINE 16C WEBSITE: WWW.PASSAVANTHOSPITAL.COM PART I, LINE 3C: PASSAVANT AREA HOSPITAL USES AN AMOUNT IN EXCESS OF 300% OF THE FPG AS A FACTOR IN DETERMINING ELIGIBILITY FOR PROVIDING DISCOUNTED CARE. THE VALUE OF 301% WAS ENTERED TO SATISFY A MANDATORY FIELD ENTRY REQUIREMENT TO QUALIFY FOR AN ELECTRONIC FILING. PART I, LINE 7: BAD DEBT EXPENSE OF $ 3,392,870 HAS BEEN EXCLUDED. COST METHODOLOGY USED WAS COST-TO-CHARGE RATIO, WHICH WAS DEVELOPED USING WORKSHEET 2. PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 3,392,870. PART II, COMMUNITY BUILDING ACTIVITIES: PASSAVANT'S COMMUNITY BUILDING ACTIVITIES INCLUDE PROMOTING ECONOMIC DEVELOPMENT BY SUPPORTING OUR AREA CHAMBER OF COMMERCE AND MAIN STREET ORGANIZATIONS, SUPPORTING ORGANIZATIONS WHO PROMOTE AND ADVOCATE FOR COMMUNITY HEALTH IMPROVEMENT, AND SUPPORTS THE COMMUNITY BY HELPING FUND TRANSPORTATION TO AND FROM THE HOSPITAL AND PROVIDER OFFICES, ALONG WITH SUPPORTING OUR LOCAL SCHOOLS AND OTHER LOCAL NON-PROFIT ORGANIZATIONS. PART III, LINE 2: PAH REPORTS PATIENT ACCOUNTS RECEIVABLE FOR SERVICES RENDERED AT NET REALIZABLE AMOUNTS FROM THIRD-PARTY PAYERS, PATIENTS AND OTHERS. THE ASSOCIATION PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS BASED UPON A REVIEW OF OUTSTANDING RECEIVABLES, HISTORICAL COLLECTION INFORMATION AND EXISTING ECONOMIC CONDITIONS. AS A SERVICE TO THE PATIENT, THE ASSOCIATION BILLS THIRD-PARTY PAYERS DIRECTLY AND BILLS THE PATIENT WHEN THE PATIENT'S LIABILITY IS DETERMINED. PATIENT ACCOUNTS RECEIVABLE ARE DUE IN FULL WHEN BILLED. ACCOUNTS ARE CONSIDERED DELINQUENT AND SUBSEQUENTLY WRITTEN OFF AS BAD DEBTS BASED ON INDIVIDUAL CREDIT EVALUATION AND SPECIFIC CIRCUMSTANCES OF THE ACCOUNT. PART III, LINE 4: THE DESCRIPTION CAN BE FOUND ON PAGE 14 OF THE AUDITED FINANCIAL STATEMENTS. PART III, LINE 8: THE AMOUNT REPORTED ON LINE 6 WAS OBTAINED FROM THE MEDICARE COST REPORT FILED BY THE ORGANIZATION. PART III, LINE 9B: PASSAVANT'S COLLECTION POLICY STATES "PASSAVANT AREA HOSPITAL WILL NOT PURSUE COLLECTION ACTION AGAINST A FINANCIALLY QUALIFIED CHARITY CARE PATIENT WHO HAS CLEARLY DEMONSTRATED THAT HE OR SHE DOES NOT HAVE SUFFICIENT INCOME OR ASSETS TO MEET ANY PART OF THEIR FINANCIAL OBLIGATION TO THE HOSPITAL. PASSAVANT AREA HOSPITAL WILL NOT USE FORCED COURT APPEARANCE TO REQUIRE THE FINANCIALLY QUALIFIED CHARITY CARE PATIENT OR RESPONSIBLE PARTY TO APPEAR IN COURT. PASSAVANT AREA HOSPITAL WILL NOT GARNISH WAGES FOR THE FINANCIALLY QUALIFIED CHARITY CARE PATIENT. ONCE CHARITY CARE STATUS IS DETERMINED, IT WILL BE APPLIED RETROACTIVELY TO ALL QUALIFYING ACCOUNTS. FOR AT LEAST 70 DAYS AFTER AN UNINSURED PATIENT'S DISCHARGE, PASSAVANT AREA HOSPITAL WILL NOT FILE A LAWSUIT TO COLLECT PAYMENT ON PATIENT'S BILL. IF AN UNINSURED PATIENT HAS REQUESTED CHARITY ASSISTANCE AND/OR APPLIED FOR OTHER COVERAGE AND IS COOPERATING WITH THE HOSPITAL, THE HOSPITAL WILL NOT PURSUE COLLECTION ACTION UNTIL A DECISION HAS BEEN MADE THAT THERE IS NO LONGER A REASONABLE BASIS TO BELIEVE PATIENT MAY QUALIFY FOR COVERAGE. WHEN THE PATIENT HAS BEEN APPROVED UNDER THE CHARITY CARE POLICY FOR A PARTIAL DISCOUNT, PASSAVANT AREA HOSPITAL WILL WORK WITH THE PATIENT OR THE RESPONSIBLE PARTY TO ESTABLISH A REASONABLE PAYMENT OPTION. IF AN UNINSURED PATIENT COMPLIES WITH A PAYMENT PLAN THAT HAS BEEN AGREED UPON BY THE HOSPITAL, PASSAVANT AREA HOSPITAL WILL NOT PURSUE COLLECTION ACTION. IF PASSAVANT AREA HOSPITAL HAS SUFFICIENT REASON TO BELIEVE THAT THE PATIENT HAS INCOME OR ASSETS TO MEET HIS OR HER OBLIGATION BUT CONTINUES WITH NON-PAYMENT, COLLECTION ACTION INCLUDING THE GARNISHMENT OF WAGES MAY BE TAKEN BY PASSAVANT AREA HOSPITAL TO ENFORCE THE TERMS OF THE PAYMENT PLAN. ONCE CHARITY CARE STATUS IS DETERMINED, IT WILL BE APPLIED RETROACTIVELY TO ALL OPEN ACCOUNTS." PART VI, LINE 2: IN ADDITION TO THE CHNA PROCESS, PASSAVANT AREA HOSPITAL ASSESSES THE HEALTH CARE NEEDS OF THE COMMUNITIES IT SERVES IN MANY DIFFERENT MANNERS. THE HOSPITAL WORKS WITH THE MORGAN COUNTY HEALTH DEPARTMENT IN DEVELOPING THE MORGAN COUNTY HEALTH PLAN. THE HOSPITAL THEN USES THE RESULTS OF THE HEALTH PLAN TO DETERMINE WHAT PROGRAMS AND SERVICES NEED TO BE OFFERED. ANOTHER SOURCE OF INFORMATION ON HEALTH CARE NEEDS IS THE MEDICAL STAFF. MEMBERS OF THE HOSPITAL'S ADMINISTRATIVE TEAM MEET REGULARLY WITH THE PHYSICIANS TO DETERMINE WHAT NEW SERVICES SHOULD BE IMPLEMENTED. THE SIXTEEN MEMBERS OF THE BOARD OF DIRECTORS, WHO REPRESENT THE DIFFERENT GEOGRAPHIC AREAS SERVED BY THE HOSPITAL, ALSO PROVIDE INPUT ON HEALTH CARE NEEDS, ALONG WITH THE VOLUNTEERS AND THE HOSPITAL'S EMPLOYEES. LASTLY, THE HOSPITAL ASKS THE PUBLIC ABOUT SERVICES THROUGH PATIENT SURVEYS AND FOCUS GROUPS. PART VI, LINE 3: THERE ARE SIGNS IN THE REGISTRATION AREAS (IN ENGLISH & SPANISH) WHICH INDICATE THE HOSPITAL TREATS PATIENTS REGARDLESS OF THEIR ABILITY TO PAY. GUIDELINES FOR PAYMENTS ON PATIENT ACCOUNTS BROCHURES ARE AT EACH REGISTRATION BOOTH FOR PATIENTS AND THE GENERAL PUBLIC. THESE BROCHURES PROVIDE PAYMENT AND FINANCIAL ASSISTANCE INFORMATION (ENGLISH & SPANISH). OUR GENERAL CONSENT FOR TREATMENT HAS A SECTION ABOUT OUR FINANCIAL ASSISTANCE PROGRAM (ENGLISH & SPANISH). THERE IS INFORMATION AVAILABLE ON THE HOSPITAL WEBSITE ABOUT OUR FINANCIAL ASSISTANCE PROGRAM. INFORMATION ABOUT BILLING AND FINANCIAL ASSISTANCE IS AVAILABLE AT BEDSIDE FOR OVERNIGHT AND SURGERY PATIENTS. PATIENT BILLING STATEMENTS ADVISE OF OUR FINANCIAL ASSISTANCE PROGRAMS AND HOW TO CONTACT US TO APPLY. SELF-PAY OVERNIGHT PATIENTS ARE CONTACTED BY SOCIAL SERVICES AND/OR PFS STAFF AND PROVIDED WITH INFORMATION ON FINANCIAL ASSISTANCE PROGRAMS. STAFF RECEIVED EDUCATION TO DIRECT PATIENT TO SOCIAL SERVICE OR PATIENT FINANCIAL SERVICE IF A PATIENT INDICATES THEY NEED ASSISTANCE WITH A BILL. PART VI, LINE 4: THE MAIN COUNTIES THAT PAH SERVES ARE CASS, MORGAN, SCOTT, MACOUPIN AND GREENE COUNTIES (PAH HAS AT LEAST 25% OF THE MARKET IN THESE ZIP CODES). THERE IS A SMALLER, SECONDARY MARKET WHERE PAH HAS AT LEAST 5%, BUT LESS THAN 25% OF THE MARKET. THE SECONDARY MARKET INCLUDES ZIP CODES IN BROWN, SCHUYLER, AND PIKE COUNTIES. OVER 90% OF CASES COME FROM THE PRIMARY MARKET.OF THE TOTAL PATIENTS SERVED BY PASSAVANT AREA HOSPITAL, 1.5 % ARE UNINSURED/RECEIVING CHARITY CARE AND 20.4 % ARE ON MEDICAID. IN THE PAH SERVICE AREA, ONE PRECINCT IN MORGAN COUNTY IS A FEDERALLY DESIGNATED MEDICALLY UNDERSERVED POPULATION, THREE TOWNSHIPS IN MACOUPIN ARE MEDICALLY UNDERSERVED AREAS (MUA), WHILE CASS, GREENE, BROWN AND SCOTT COUNTIES ARE ALL MUA'S. PATIENTS IN THE PASSAVANT AREA HOSPITAL SERVICE AREA SOMETIMES TRAVEL FOR SERVICE TO OTHER HOSPITALS IN THE AREA, THE CLOSEST BEING MEMORIAL MEDICAL CENTER AND ST. JOHN'S HOSPITAL IN SPRINGFIELD, IL, WHICH ARE 30 MILES FROM PASSAVANT'S PHYSICAL LOCATION IN JACKSONVILLE, IL. THE COUNTIES WHICH MAKE UP PASSAVANT'S SERVICE AREA ARE ALL RURAL AREAS. DEMOGRAPHICS OF THE PRIMARY SERVICE AREAS ARE (ESTIMATED AS OF 2014):MORGAN COUNTY - POPULATION APPROX. 34,929; PER CAPITA INCOME $24,822; MEDIAN HOUSEHOLD INCOME $46,524; PERCENTAGE OF PERSONS BELOW THE POVERTY LEVEL 15.1%CASS COUNTY - POPULATION APPROX. 13,156; PER CAPITA INCOME $23,423; MEDIAN HOUSEHOLD INCOME $47,443; PERCENTAGE OF PERSONS BELOW THE POVERTY LEVEL 13.2%SCOTT COUNTY - POPULATION APPROX. 5,300; PER CAPITA INCOME $24,395; MEDIAN HOUSEHOLD INCOME $48,500; PERCENTAGE OF PERSONS BELOW THE POVERTY LEVEL 12.0%MACOUPIN COUNTY - POPULATION APPROX. 47,700; PER CAPITA INCOME $25,402; MEDIAN HOUSEHOLD INCOME $50,911; PERCENTAGE OF PERSONS BELOW THE POVERTY LEVEL 12.9%GREENE COUNTY - POPULATION APPROX. 13,800; PER CAPITA INCOME $22,483; MEDIAN HOUSEHOLD INCOME $43,178; PERCENTAGE OF PERSONS BELOW THE POVERTY LEVEL 16.2% PART VI, LINE 5: PASSAVANT AREA HOSPITAL HAS A BOARD OF DIRECTORS MADE UP OF MEDICAL, BUSINESS, AGRICULTURE AND COMMUNITY LEADERS WHO RESIDE IN THE HOSPITAL'S PRIMARY SERVICE AREA. THESE VOLUNTEERS DONATE THEIR TIME IN THEIR OVERSIGHT ROLE AND ARE INVOLVED IN THE DECISION-MAKING PROCESS FOR THE HOSPITAL. PAH HAS A TASK FORCE THAT LEADS THE COMMUNITY NEEDS ASSESSMENT PROCESS. MORE THAN 200 PEOPLE VOLUNTEER AT THE HOSPITAL AS AMBASSADORS, MESSENGERS, AND A WIDE RANGE OF OTHER VOLUNTEER ROLES. PAH HAS AN OPEN MEDICAL STAFF THAT ALLOWS MEMBERSHIP TO ANYONE WHO MEETS CREDENTIALING REQUIREMENTS. THE HOSPITAL PARTICIPATES IN MEDICARE, MEDICAID, CHAMPUS, TRICARE AND OTHER GOVERNMENT PROGRAMS AND PROVIDES FINANCIAL ASSISTANCE AND SLIDING SCALE DISCOUNTS ACCORDING TO BOARD-APPROVED CHARITY CARE POLICIES. PAH HAS A 24/7 EMERGENCY DEPARTMENT PROVIDING SERVICE TO ALL PERSONS, REGARDLESS OF ABILITY TO PAY. THE HOSPITAL ALSO PROVIDES A MEDICARE/INSURANCE CONSULTANT TO HELP PATIENTS UNDERSTAND AND COPE WITH PAPERWORK AND BILLING THAT FOLLOWS A HOSPITAL STAY. THE CONSULTANT IS AVAILABLE TO ASSIST DISCHARGED PATIENTS WITH THE FILING OF MEDICARE/INSURANCE FORMS AND HELPS CLIENTS UNDERSTAND THE COMPREHENSIVE PROCESS OF FILING CLAIMS. THERE IS NO CHARGE FOR THIS SERVICE.PASSAVANT AREA HOSPITAL IS A SOLE COMMUNITY HOSPITAL WITH 93 STAFFED BEDS, IS STAFFED BY 900 FULL AND PART-TIME EMPLOYEES, AND AN ACTIVE MEDICAL STAFF OF 70 PHYSICIANS. SERVICES OFFERED INCLUDE 24-HOUR EMERGENCY MEDICINE, GENERAL ACUTE INPATIENT CARE, WOUND CARE, ORTHOPEDICS, AND SURGERY, AS WELL AS A FULL RANGE OF OUTPATIENT REHABILITATION AND THERAPY AND DIAGNOSTIC TESTING. A FIXED MRI UNIT AND UPGRADED CT SCAN OFFER COMMUNITY MEMBERS LOCAL AND CONVENIENT ACCESS TO MANY DIAGNOSTIC TESTS. PAH'S EMERGENCY DEPARTMENT HAS TRADITIONALLY SERVED AS A SAFETY NET HEALTHCARE PROVIDER FOR THE UNINSURED AND UNDERINSURED WHO DO NOT HAVE PRIMARY CARE PHYSICIANS.PASSAVANT AREA HOSPITAL USED SURPLUS FUNDS TO IMPROVE COMMUNITY HEALTH BY PURCHASING A NEW MRI MACHINE WHICH IS A BETTER DIAGNOSTIC TOOL THAN THE PREVIOUS MACHINE; AND SUPPORTING A MOBILE FOOD PANTRY MULTIPLE TIMES THROUGH THE YEAR. PAH EXPANDED SERVICES IN CARDIOLOGY, MAMMOGRAPHY, AND INTERVENTIONAL RADIOLOGY CAPABILITIES. PAH ALSO COLLABORATED WITH THE MIA WARE FOUNDATION IN PROVIDING FREE MAMMOGRAMS FOR THOSE WHO CANNOT AFFORD THEM. RECOGNIZING THE NEED FOR INCREASED NEED FOR PSYCHIATRIC CARE IN OUR COMMUNITY PAH IS EXPANDING PSYCHIATRIC SERVICES. PASSAVANT PHYSICIAN ASSOCIATION RECRUITED A NEW PSYCHIATRIST AND PAH BEGAN CONSTRUCTION ON AN INPATIENT PSYCHIATRIC UNIT. PAH INCREASED THE COMMUNITY ACCESS TO CANCER SCREENINGS BY PARTNERING WITH THE NATIONAL KIDNEY FOUNDATION TO OFFER THE KIDNEY MOBILE SCREENINGS. PAH ALSO SPONSORED A SKIN CANCER SCREENING EVENING IN COOPERATION WITH A LOCAL DERMATOLOGIST, PROVIDING FREE SKI CANCER SCREENINGS. PAH PROVIDES CASH AND IN-KIND DONATIONS TO AREA NON-PROFIT ORGANIZATIONS. PAH PROVIDES FREE MEDICARE CONSULTING SERVICES TO SENIORS. PASSAVANT PROVIDES SPEAKERS, SCREENINGS AND HEALTH FAIRS FOR FREE AT THE JACKSONVILLE AREA SENIOR CENTER. IT ALSO CONDUCTS A "COMMUNITY HEALTH CHECK" AT THE CENTER THE FIRST WEDNESDAY OF EACH MONTH. IN FISCAL YEAR 2015, PAH PROVIDED $7.2 MILLION IN CHARITY CARE AND BAD DEBT CHARGES.PASSAVANT AREA HOSPITAL HAS ALSO COLLABORATED WITH THE MORGAN COUNTY HEALTH DEPARTMENT IN REOPENING A CLINIC TO DIAGNOSE AND TREAT SEXUALLY TRANSMITTED DISEASES, WHICH THE PUBLIC HEALTH DEPARTMENT HAD TO CLOSE DUE TO LACK OF FUNDING. PAH PROVIDES FINANCIAL SUPPORT TO THIS CLINIC, AS WELL AS PHYSICIANS AND NURSES VOLUNTEERING THEIR TIME TO SEE PATIENTS AT THE CLINIC. PAH ALSO WORKS WITH LOCAL SCHOOLS TO IMPROVE CURRICULUM ON REPRODUCTIVE HEALTH, AND SUPPORTS THE PARTNERSHIP FOR SUBSTANCE MISUSE, A LOCAL COALITION, IN ITS WORK TO ADDRESS ADOLESCENT SUBSTANCE ABUSE. PAH HOSTS SEVERAL SUPPORT GROUPS FOR THE COMMUNITY: BEREAVED PARENTS, AUTISM, ALZHEIMER'S, BREASTFEEDING, DIABETES, GRIEF, GRANDPARENTS RAISING CHILDREN, PARKINSON'S AND NEUROMUSCULAR DISORDERS, STROKE AND EPILEPSY. PART VI, LINE 6: PASSAVANT AREA HOSPITAL IS AN AFFILIATE OF MEMORIAL HEALTH SYSTEM.PASSAVANT AREA HOSPITAL, A 501(C)(3) CORPORATION, IS THE SOLE CORPORATE MEMBER OF PASSAVANT PHYSICIAN ASSOCIATION, A PHYSICIAN GROUP. PASSAVANT PHYSICIAN ASSOCIATION (PPA) IS A GROUP OF 6 PHYSICIAN OFFICES THAT OFFER A VARIETY OF SERVICES: SURGERY; EAR, NOSE & THROAT; PSYCHIATRIC; INTERNAL MEDICINE; WOUND CARE; AND OBSTETRICS/GYNECOLOGY. COMPRISED OF MORE THAN 17 PHYSICIANS AND MID-LEVEL PROVIDERS, IT EMPLOYS MORE THAN 50 PEOPLE AND PROVIDES 25,000+ PATIENT VISITS EACH YEAR. PPA PROVIDES COMMUNITY BENEFITS BY PROVIDING COMMUNITY EDUCATION PROGRAMS ON VARIOUS TOPICS, SUCH AS STROKE, DIABETES, DEPRESSION, HOSPICE CARE, AND PATIENT SAFETY. PART VI, LINE 7, REPORTS FILED WITH STATES IL 1 ILLINOIS HOSPITAL RESEARCH AND EDUCATION FOUNDATION 1151 EAST WARRENVILLE ROAD NAPERVILLE IL 60566 237421930 501(C)(3) 32772 TO ADDRESS THE DISPARATE AND NEGATIVE EFFECTS OF THE ILLINOIS MEDICAID PROGRAM EXPERIENCED BY HOSPITALS AND HEALTHCARE SYSTEMS IN ILLINOIS. 1 PART I, LINE 2: GRANTS PAID TO ILLINOIS HOSPITAL RESEARCH AND EDUCATIONAL ASSOCIATION ARE PAID AS PART OF A VOLUNTARY STATE MEDICAID REALLOCATION PROGRAM KNOWN AS THE HOSPITAL MUTUAL ASSISTANCE PROGRAM. NO FORMAL POLICY EXISTS TO MONITOR THE USE OF THESE GRANTS. 0 1 0 0 0 0 0 0 0 STEVEN LILLPOP MD BOARD MEMBER 0 430505 0 47221 0 119032 0 130350 0 77712 0 804820 0 36929 BABU ELADASARI MD BOARD MEMBER (EFF JAN 15) 0 304782 0 0 0 0 0 15600 0 17664 0 338046 0 0 CHARLES SHEAFF MD BOARD MEMBER (THRU DEC 14) 0 374976 0 0 0 0 0 15600 0 11134 0 401710 0 0 DOUGLAS RAHN DBA PRESIDENT & CEO 0 443840 0 188757 0 39568 0 271383 0 20512 0 964060 0 0 DAVID BOLEN VICE PRESIDENT & CFO 202737 0 0 0 0 0 12357 0 15139 0 230233 0 0 0 MARK RUFF STAFF ANESTHETIST 302182 0 0 0 0 0 15032 0 40891 0 358105 0 0 0 DAVID TONRY STAFF ANESTHETIST 275373 0 0 0 0 0 15600 0 36280 0 327253 0 0 0 MICHAEL DUNSETH STAFF ANESTHETIST 261061 0 0 0 0 0 8205 0 32117 0 301383 0 0 0 JON GREGORY STAFF ANESTHETIST 252655 0 0 0 0 0 15518 0 36388 0 304561 0 0 0 RANDALL MOORE DIRECTOR PERIOPERATIVE SERVICES 244305 0 0 0 0 0 14928 0 36803 0 296036 0 0 0 CHESTER WYNN PRESIDENT & CEO 71505 0 0 0 47071 0 7092 0 4426 0 130094 0 0 0 PART I, LINE 3 COMPENSATION AND BENEFITS RECEIVED BY DOUGLAS RAHN, PRESIDENT AND CEO OF PASSAVANT MEMORIAL AREA HOSPITAL, WAS COMPRISED OF THE FOLLOWING COMPONENTS; BASE COMPENSATION, INCENTIVE COMPENSATION, OTHER COMPENSATION, RETIREMENT/DEFERRED COMPENSATION AND OTHER NONTAXABLE BENEFITS. COMPENSATION FOR MR. RAHN IS DETERMINED BY MEMORIAL HEALTH SYSTEM. BASE COMPENSATION LEVELS WERE SET BY THE MHS BOARD AT THE 50TH PERCENTILE OF THE RELEVANT COMPENSATION RANGE, AS DETERMINED BY INDEPENDENT COMPENSATION CONSULTANTS. INCENTIVE COMPENSATION WAS CONTINGENT ON THE ACHIEVEMENT OF SPECIFIC PERFORMANCE METRICS OF MHS, AS DEFINED BY THE MHS BOARD. OTHER COMPENSATION IS COMPRISED PRIMARILY OF DEFERRED COMPENSATION PAYOUTS MADE DURING THE YEAR FOR COMPENSATION PREVIOUSLY EARNED IN PRIOR YEARS. RETIREMENT COMPENSATION REFLECTS AN INCREASE IN RETIREMENT BENEFITS OWED BY MHS UPON RETIREMENT OF MR. RAHN. THIS INCREASE WAS DRAMATICALLY IMPACTED BY ACTUARIAL ASSUMPTIONS OF THE RETIREMENT PLAN, WHICH HAS HISTORICALLY INCLUDED DRAMATIC CHANGES IN THE DISCOUNT RATE. NONTAXABLE BENEFITS REFLECT THE VALUE OF HEALTH (MEDICAL, DENTAL, LIFE INSURANCE) BENEFITS RECEIVED DURING THE YEAR AS WELL AS CHANGES IN ACTUARIAL VALUE OF THE POSTRETIREMENT HEALTH CARE INSURANCE REIMBURSEMENT PLAN. PART I, LINE 4B THE ORGANIZATION, OR A RELATED ORGANIZATION, MEMORIAL HEALTH SYSTEM, PROVIDES CERTAIN SUPPLEMENTAL RETIREMENT BENEFITS TO THE FOLLOWING OFFICERS, KEY EMPLOYEES, AND HIGHEST COMPENSATED EMPLOYEES: STEVEN LILLPOP, M.D., $41,913 AND DOUGLAS RAHN, D.B.A., $253,383. THESE BENEFITS ARE PROVIDED THROUGH A NONQUALIFIED DEFERRED COMPENSATION PLAN, UNDER WHICH THE BENEFITS BEING EARNED ARE SUBJECT TO A "SUBSTANTIAL RISK OF FORFEITURE." THE SUPPLEMENTAL RETIREMENT BENEFITS ARE STRUCTURED TO PROVIDE A RETENTION INCENTIVE THAT HAS BEEN DETERMINED BY THE LEADERSHIP COMPENSATION COMMITTEE OF THE BOARD OF DIRECTORS OF MEMORIAL HEALTH SYSTEM TO BE OF SUBSTANTIAL VALUE TO THE ORGANIZATION. THE FOLLOWING CURRENT OR FORMER OFFICERS, KEY EMPLOYEES, AND HIGHEST COMPENSATED EMPLOYEES RECEIVED DEFERRED COMPENSATION PAYOUTS IN THE CALENDAR YEAR FROM THE ORGANIZATION OR A RELATED ORGANIZATION, MEMORIAL HEALTH SYSTEM: STEVEN LILLPOP, M.D., $98,422 AND DOUGLAS RAHN, D.B.A, $12,055. TO BECOME ENTITLED TO THE BENEFITS PROVIDED, EACH COVERED EMPLOYEE MUST MEET SUBSTANTIAL REQUIREMENTS RELATING TO FURTHER EMPLOYMENT. UNTIL THOSE REQUIREMENTS ARE SATISFIED, IF EVER, THE EMPLOYEE IS NOT ENTITLED TO THESE AMOUNTS. IF THE EMPLOYEE WERE TO HAVE TERMINATED EMPLOYMENT VOLUNTARILY IN THE YEAR TO WHICH THIS RETURN APPLIES AND NOT MET THESE SUBSTANTIAL REQUIREMENTS, THESE SUPPLEMENTAL RETIREMENT BENEFITS WOULD HAVE BEEN FORFEITED. THESE SUPPLEMENTAL RETIREMENT BENEFITS ARE PART OF A RETIREMENT PROGRAM THAT PROVIDES RETIREMENT INCOME FOR ALL YEARS OF SERVICE THAT THE EMPLOYEE PROVIDES TO THE ORGANIZATION. ACCORDINGLY, ANY RETIREMENT BENEFITS SHOULD BE VIEWED AS APPLYING TO THE ENTIRE LENGTH OF THE EMPLOYEE'S SERVICE. THE LEADERSHIP COMPENSATION COMMITTEE OF THE MHS BOARD APPROVES ALL RETIREMENT BENEFITS, TOGETHER WITH ALL OTHER FORMS OF COMPENSATION AND BENEFITS FOR THESE AND OTHER SENIOR LEADERS, IN A MANNER INTENDED TO QUALIFY FOR THE "REBUTTABLE PRESUMPTION OF REASONABLENESS" UNDER FEDERAL INCOME TAX LAW. A CITY OF JACKSONVILLE ILLINOIS 376001700 469590AA1 2010-12-01 28980000 SEE PART IV 0 0 0 A 3945000 28980000 28980000 1 0 1 1 A 0 1 1 1 0 0.02650 0.02650 0 0 1 A 1 1 0 0 0 1 A 1 SCHEDULE K, PART 1, BOND ISSUES DESCRIPTION OF PURPOSE: REISSUANCE RESULTING IN CURRENT REFUNDING OF PREVIOUSLY ISSUED $28,980,000 CITY OF JACKSONVILLE, ILLINOIS ADJUSTABLE RATE DEMAND INDUSTRIAL REVENUE BONDS,SERIES 2006A AND SERIES 2006B (THE PASSAVANT MEMORIAL HOSPITAL ASSOCIATION PROJECT). JAKE HURWITZ SON OF MMC AND MHS BOARD MEMBER 43117 EMPLOYMENT 0 LEANNA WYNN WIFE OF FORMER BOARD MEMBER 130887 EMPLOYMENT 0 SHERYL ROBERTS DAUGHTER OF PAH BOARD MEMBER 82088 EMPLOYMENT 0 FORM 990, PART VI, SECTION A, LINE 6 MEMORIAL HEALTH SYSTEM IS THE SOLE CORPORATE MEMBER OF PASSAVANT MEMORIAL AREA HOSPITAL ASSOCIATION. MEMORIAL HEALTH SYSTEM CORPORATION CONTAINS 105 INDIVIDUAL MEMBERS WHO ELECT THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 7A THE CORPORATE MEMBER OF THE CORPORATION ELECTS THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 7B PASSAVANT MEMORIAL AREA HOSPITAL ASSOCIATION'S BYLAWS STATE THE CORPORATE MEMBER SHALL ELECT THE DIRECTORS OF THE CORPORATION IN CONJUNCTION WITH THE BOARD OF GOVERNORS AND BOARD OF DIRECTORS. THE CORPORATE MEMBER WILL WORK WITH THE BOARD OF DIRECTORS TO ELECT THE PRESIDENT AND CHIEF EXECUTIVE OFFICER. THE CORPORATE MEMBER WILL APPROVE CAPITAL AND OPERATING BUDGETS, STRATEGIC PLANS, AND APPROVE ANY VOLUNTARY DISSOLUTION, MERGER, OR CONSOLIDATION. THE CORPORATE MEMBER SHALL APPROVE ANY AMENDMENT TO BYLAWS OR ARTICLES OF INCORPORATION. IN ADDITION, THE CORPORATE MEMBER HAS THE POWER TO REMOVE THE PRESIDENT WITH MUTUAL AGREEMENT OF THE BOARD OF DIRECTORS OR THE REMOVAL OF ANY DIRECTOR WITH CAUSE. THE CORPORATE MEMBER HAS APPROVAL POWER FOR THE CAPITAL EXPENDITURES OVER $1,000,000, GUARANTY OF DEBT GREATER THAN $250,000, WITH OR WITHOUT A MORTGAGE, OR OTHER TRANSACTIONS MATERIAL IN NATURE WITH AFFILIATE CORPORATIONS. CORPORATE MEMBERS HAVE THE POWER TO APPROVE INDEPENDENT AUDITORS, APPROVE CONTRACTS PROVIDING HEALTHCARE SERVICES TO BENEFICIARIES OF MANAGED CARE CONTRACTS AND APPROVAL OF APPLICATIONS TO THE IL HEALTH FACILITIES PLANNING BOARD. MEMBERS ALSO APPROVE SALES/TRANSFERS OF ASSETS TO NON-AFFILIATE ENTITIES, IF ASSETS ARE OVER $500,000. THE CORPORATE MEMBER SHALL APPROVE SIGNIFICANT CHANGES IN THE CORPORATION'S INSURANCE AND CONTRACTS INVOLVING GOODS/SERVICES WITH A VALUE OVER $1,000,000 FOR CAPITAL OR $1,500,000 IN AGGREGATE FOR OPERATING AND CAPITAL BUDGETS, NOT PREVIOUSLY APPROVED. THE CORPORATE MEMBER SHALL APPROVE OF PHYSICIAN SERVICE CONTRACTS OVER $400,000, APPROVE REAL ESTATE TRANSACTIONS, AND APPROVE ANY CHANGES TO MASTER OR LONG-TERM INSTITUTIONAL PLANS. FORM 990, PART VI, SECTION B, LINE 11 A FINAL DRAFT COPY OF THE PAH FORM 990 AND ALL ATTACHMENTS IS PROVIDED TO ALL OF THE PASSAVANT MEMORIAL AREA HOSPITAL ASSOCIATION BOARD OF DIRECTORS PRIOR TO FILING. AT THE BOARD MEETING, A PRESENTATION IS MADE BY THE CFO TO THE BOARD, FOLLOWED BY A QUESTION AND ANSWER SESSION. ALL QUESTIONS AND COMMENTS ARISING FROM THIS REVIEW ARE ADDRESSED PRIOR TO SUBMISSION OF THE RETURN TO THE APPROPRIATE TAXING AUTHORITIES. FORM 990, PART VI, SECTION B, LINE 12C BOARD MEMBERS AND KEY EMPLOYEES ARE REQUIRED TO DISCLOSE CONFLICTS OF INTEREST BY FILING SIGNED STATEMENTS WITH THE ORGANIZATION. THE BOARD MEMBERS COMPLETE THE CONFLICT OF INTEREST POLICY ON A YEARLY BASIS. THEY ARE REQUIRED TO DISCLOSE ANY CONFLICTS WHEN INFORMATION IS GATHERED TO PREPARE FORM 990. IF THEY HAVE A CONFLICT, THE BOARD MEMBERS EXCUSE THEMSELVES FROM ANY APPLICABLE VOTES. IF THERE IS A QUESTION OF WHETHER OR NOT THEY HAVE A CONFLICT, EITHER THE CEO OR THE CFO WILL INVESTIGATE THE ISSUE AND CONSULT WITH THE BOARD CHAIR, WHO WILL MAKE THE FINAL DETERMINATION. EMPLOYEES SIGN A CODE OF CONDUCT STATEMENT ANNUALLY, WHICH INCLUDES A SECTION ON CONFLICT OF INTEREST. EMPLOYEES ARE ALSO REQUIRED TO DISCLOSE ANY POTENTIAL CONFLICTS OF INTEREST. IF THEY HAVE A CONFLICT, THEY CANNOT HAVE ANY DECISION-MAKING POWERS REGARDING ANY OF THEIR AREAS OF CONFLICT. FORM 990, PART VI, SECTION B, LINE 15 THE ORGANIZATION PARTICIPATES IN SEVERAL NATIONAL AND REGIONAL SURVEYS WHERE DATA IS OBTAINED ON VARIOUS POSITIONS SUCH AS CEO, CFO, CNO, ETC. THIS INFORMATION IS THEN PROVIDED TO THE BOARD EXECUTIVE COMMITTEE FOR REVIEW AND APPROVAL. FOR OTHER OFFICERS AND KEY EMPLOYEES, A CUSTOMIZED SURVEY CONDUCTED BY INTEGRATED HEALTHCARE STRATEGIES COMPARES THE COMPENSATION DATA PROVIDED BY THE ORGANIZATION TO THE STATISTICAL INFORMATION THEY HAVE. INTEGRATED HEALTHCARE STRATEGIES GENERATES A TRUE MARKET AVERAGE REPORT THAT COMPARES THE ORGANIZATIONS SALARIES FOR A POSITION AND ASSOCIATED MINIMUM, 1ST QUARTILE, MIDPOINT, 3RD QUARTILE, AND MAXIMUM SALARY POINTS. THE KEY EMPLOYEE DATA IS REVIEWED BY OUR CEP, CFO, AND HR DIRECTOR AND MARKET COMPARATIVE SALARY ADJUSTMENTS ARE MADE AS NECESSARY. FORM 990, PART VI, SECTION C, LINE 19 COPIES OF THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE MADE AVAILABLE UPON INDIVIDUAL REQUEST. THE AUDITED FINANCIAL STATEMENTS ARE POSTED ON THE HOSPITAL'S WEBSITE. THESE DOCUMENTS ARE AVAILABLE FOR THE SAME PERIOD OF TIME AS SET FORTH IN IRC SECTION 6104(D). FORM 990, PART XI, LINE 9: CHANGE IN FAIR VALUE OF INTEREST RATE SWAPS -237,237. CONTRIBUTIONS & OTHER 660,789. DECREASE IN PERMANENTLY RESTRICTED NET ASSETS -412,879. INCREASE IN TEMPORARILY RESTRICTED NET ASSETS 892,543. EQUITY IN INCOME OF AFFILIATE-URNA 3,772,188. NONOPERATING CHANGES -708,342. EQUITY TRANSFERS TO RELATED ORGANIZATIONS -37,462,587. MEMORIAL HEALTH SYSTEM 701 NORTH FIRST STREET SPRINGFIELD IL 627810001 371110690 UMBRELLA IL 501(C)(3) 509 (A) (3) TYPE II N/A 0 MEMORIAL MEDICAL CENTER 701 NORTH FIRST STREET SPRINGFIELD IL 627810001 370661220 HOSPITAL SERVICES IL 501(C)(3) 170(B) (1) (A) (III) MEMORIAL HEALTH SYSTEM 0 MEMORIAL HEALTH VENTURES 701 NORTH FIRST STREET SPRINGFIELD IL 627810001 363492266 HEALTHCARE ACTIVITIES IL 501(C)(3) 509 (A) (2) MEMORIAL HEALTH SYSTEM 0 ABRAHAM LINCOLN MEMORIAL HOSPITAL 200 STAHLHUT DRIVE LINCOLN IL 62656 370723793 HOSPITAL SERVICES IL 501(C)(3) 170(B) (1) (A) (III) MEMORIAL HEALTH SYSTEM 0 TAYLORVILLE MEMORIAL HOSPITAL 201 EAST PLEASANT TAYLORVILLE IL 62568 370661250 HOSPITAL SERVICES IL 501(C)(3) 170(B) (1) (A) (III) MEMORIAL HEALTH SYSTEM 0 MEMORIAL HOME SERVICES 720 NORTH BOND STREET SPRINGFIELD IL 627024915 370714225 HOME HEALTH AND HOSPICE IL 501(C)(3) 509 (C) (2) MEMORIAL HEALTH SYSTEM 0 MEMORIAL PHYSICIAN SERVICES 701 NORTH FIRST STREET SPRINGFIELD IL 627810001 371181194 HEALTH CLINICS IL 501(C)(3) 509 (A) (2) MEMORIAL HEALTH SYSTEM 0 MEMORIAL MEDICAL CENTER FOUNDATION 701 NORTH FIRST STREET SPRINGFIELD IL 62781 371110301 GRANTS TO HOSPITAL, OTHER CHARITABLE ORGANIZATIONS, AND SCHOLARSHIPS IL 501(C)(3) 170(B) (1) (A) MEMORIAL MEDICAL CENTER 0 TAYLORVILLE MEMORIAL HOSPITAL FOUNDATION 201 EAST PLEASANT TAYLORVILLE IL 62568 371337485 GRANTS TO OTHER CHARITABLE ORGANIZATIOINS AND HOSPITALS IL 501(C)(3) 170 (B) (1) (A) (VI) N/A 0 MENTAL HEALTH CENTERS OF CENTRAL ILLINOIS 710 NORTH EIGHTH STREET SPRINGFIELD IL 627026395 370646367 TRAINING, PSYCHIATRIC, AND RESIDENT SERVICES FOR MENTALLY ILL AND DISABLED IL 501(C)(3) 170(B) (1) (A) (VI) MEMORIAL HEALTH SYSTEM 0 ABRAHAM LINCOLN HEALTHCARE FOUNDATION 200 STAHLHUT DRIVE LINCOLN IL 62656 363492268 GRANTS TO OTHER CHARITABLE ORGANIZATIONS AND HOSPITALS IL 501(C)(3) 170(B) (1) (A) (VI) MEMORIAL HEALTH SYSTEM 0 SPRINGFIELD RESIDENTIAL SERVICES 710 NORTH EIGHTH STREET SPRINGFIELD IL 62702 371298589 RESIDENTIAL HUD HOUSING PROJECT FOR MENTALLY ILL IL 501(C)(3) 170(B) (1) (A) (VI) MENTAL HEALTH CENTERS OF CENTRAL ILLINOIS 0 JACKSONVILLE CRNA'S INC 1600 WEST WALNUT STREET JACKSONVILLE IL 62650 273083265 CRNA SERVICES IL 501(C)(3) 509 (A) (3), TYPE 1 PASSAVANT MEMORIAL AREA HOSPITAL ASSOCIATION 1 PASSAVANT AREA HOSPITAL FOUNDATION 1600 WEST WALNUT STREET JACKSONVILLE IL 62650 471037396 SUPPORTING THE HOSPITAL IL 501(C)(3) 509 (A) (3) TYPE I PASSAVANT MEMORIAL AREA HOSPITAL ASSOCIATION 1 PASSAVANT MEMORIAL AREA AUXILIARY 1600 WEST WALNUT STREET JACKSONVILLE IL 62650 370890067 SUPPORTING THE HOSPITAL IL 501(C)(3) 509 (A) (3) TYPE III N/A 0 PASSAVANT PHYSICIAN ASSOCIATION 1600 WEST WALNUT STREET JACKSONVILLE IL 62650 261200566 PHYSICIAN SERVICES IL PASSAVANT MEMORIAL AREA HOSPITAL ASSOCIATION C 4557877 1107631 1.00000 1 CHARITABLE REMAINDER TRUSTS (12) INVESTMENT IL 0 MEMORIAL HOME SERVICES OF CENTRAL ILLINOIS INC 701 NORTH FIRST STREET SPRINGFIELD IL 62781 371190216 PROVIDE DURABLE MEDICAL EQUIPMENT AND SUPPLIES TO PATIENTS IL MEMORIAL HOME SERVICES C 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 0 1 0 1 1 PASSAVANT AREA HOSPITAL FOUNDATION C 328352 FMV PASSAVANT AREA HOSPITAL FOUNDATION R 409748 FMV PASSAVANT PHYSICIAN ASSOCIATION R 26192448 FMV JACKSONVILLE CRNA INC R 12660390 FMV JACKSONVILLE CRNA INC S 1800000 FMV PART IV PART IV, IDENTIFICATION OF REALTED ORGANIZATIONS TAXABLE AS CORP OR TRUST: NAME OF RELATED ORGANIZATION: PASSAVANT PHYSICIAN ASSOCIATION DIRECT CONTROLLING ENTITY: PASSAVANT MEMORIAL AREA HOSPITAL ASSOCIATION PART II NAME OF RELATED ORGANIZATION: PASSAVANT AREA HOSPITAL FOUNDATION DIRECT CONTROLLING ENTITY: PASSAVANT MEMORIAL AREA HOSPITAL ASSOCIATION PART II, IDENTIFICATION OF RELATED TAX-EXEMPT ORGANIZATIONS: NAME OF RELATED ORGANIZATION: JACKSONVILLE CRNA'S INC. DIRECT CONTROLLING ENTITY: PASSAVANT MEMORIAL AREA HOSPITAL ASSOCIATION