2014-03-29T10:24:39-05:00 2013-09-30 351178661 BLUE & CO LLC ONE AMERICAN SQUARE 2200 INDIANAPOLIS IN 46282 990 2012-10-01 351064295 DEKALB MEMORIAL HOSPITAL INC DEKA 2609254600 1316 EAST SEVENTH STREET AUBURN IN 46706 AMY CROUCH 2609254600 2014-03-24 1 AMBER KOCHER CPA P01286298 3176334705 2012 2015-11-30 17:44:51Z DEKALB HEALTH AMY CROUCH 1316 EAST SEVENTH STREET AUBURN IN 46706 63127968 0 X WWW.DEKALBHEALTH.COM X 1964 IN TO PROVIDE ACUTE, SUBACUTE AND OUTPATIENT MEDICAL SERVICES TO RURAL NORTHEASTERN INDIANA. 13 13 670 50 69488 -1668 135233 103983 59683726 57084955 621375 451741 1326050 641181 61766384 58281860 77646 107509 0 0 30517482 31538961 0 0 37360 29718274 27486171 60313402 59132641 1452982 -850781 68069935 67490054 17637023 16350782 50432912 51139272 X PROMOTE, PRESERVE, RESTORE HEALTH 0 0 54142413 107509 57656648 DEKALB HEALTH IS A 47 BED HOSPITAL IN RURAL INDIANA PROVIDING ACUTE, SUBACUTE AND OUTPATIENT SERVICES. FOR THE FISCAL YEAR ENDING SEPTEMBER 30, 2013, THERE WERE 2,438 TOTAL ADMISSIONS; 18,197 TOTAL EMERGENCY ROOM VISITS; AND 7,833 TOTAL HOME HEALTH CARE VISITS. THE HOSPITAL PROVIDES CARE WITHOUT CHARGE OR AT AMOUNTS LESS THAN ITS ESTABLISHED RATES TO PATIENTS WHO MEET CERTAIN CRITERIA UNDER ITS CHARITY CARE POLICY. THE HOSPITAL DOES NOT PURSUE COLLECTION OF QUALIFIED CHARITY CARE AMOUNTS. THE DIRECT AND INDIRECT COSTS FURNISHED UNDER ITS CHARITY CARE POLICY DURING THE YEAR WERE APPROXIMATELY $1,155,000.AT DEKALB HEALTH, OUR INVESTMENTS IN STATE-OF-THE-ART FACILITIES AND PARTNERSHIPS WITH TOP FAMILY PHYSICIANS AND SPECIALTY GROUPS MEAN THAT YOU NEVER HAVE TO LOOK PAST DEKALB COUNTY FOR THE VERY BEST CARE. OUR COMMITMENT IS ALSO REFLECTED IN OUR INVESTMENTS OF TIME, TALENTS AND RESOURCES IN LOCAL SCHOOLS, BUSINESSES, CHARITABLE ORGANIZATIONS AND OTHER WORTHY CAUSES TO HELP ENSURE A HEALTHIER COMMUNITY. WE'RE PROUD TO BE YOUR NEIGHBOR, AND YOU CAN BE SURE WE'LL BE HERE, TAKING CARE OF YOU FOR GENERATIONS TO COME. THANKS TO THE VISION OF OUR LEADERSHIP, DEKALB HEALTH HAS TAKEN NUMEROUS STEPS FORWARD. WHILE MANY OF OUR MILESTONES ARE IN PLAIN SIGHT SUCH AS THE NEW ER, EICU, REGISTRATION AREA, IMAGING, LABORATORY, AND RESPIRATORY CENTERS, BUT MANY OF OUR ACHIEVEMENTS ARE BEHIND THE SCENES. WE HAVE FORGED NEW PARTNERSHIPS WITH PHYSICIAN GROUPS, SO THAT PEOPLE IN OUR REGION NOW HAVE ACCESS TO ALMOST EVERY MEDICAL SPECIALTY RIGHT HERE ON OUR CAMPUS. WE HAVE ALSO MADE SIGNIFICANT INVESTMENTS IN NEW TECHNOLOGY, SUCH AS A STATE-OF-THE-ART MONITORING SYSTEM FOR CRITICALLY ILL PATIENTS AND THE MOVE TO ELECTRONIC MEDICAL RECORDS. MOST IMPORTANTLY, OUR PEOPLE CONTINUE TO DISTINGUISH THEMSELVES AS THE MOST COMPASSIONATE CAREGIVERS YOU'LL FIND ANYWHERE, AND WE CONTINUE TO DONATE TIME AND RESOURCES IN SUPPORT OF SCHOOLS, BUSINESSES, AND ORGANIZATIONS TO ENSURE A STRONG, HEALTHY COMMUNITY. AT DEKALB HEALTH, WE HAVE REARMED OUR COMMITMENT TO BEING YOUR INDEPENDENT, NOT-FOR-PROFIT COMMUNITY HOSPITAL. WITH EVERY NEW INVESTMENT, WE'RE BRINGING WORLD-CLASS HEALTHCARE HOME TO YOU. (CONTINUATION FROM PROGRAM SERVICE ACCOMPLISHMENT PAGE 2) WE CELEBRATE THE UNIQUE BOND THAT EXISTS BETWEEN THE HOSPITAL AND ITS COMMUNITY. OURS IS A RICH HERITAGE OF INDEPENDENCE, DETERMINATION AND A COMMITMENT TO TAKING CARE OF THE INDIVIDUALS AND FAMILIES WE SERVE. 54142413 1 1 0 1 0 0 0 0 0 1 1 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 1 0 0 0 0 0 0 0 0 1 1 0 0 0 1 60 0 1 670 1 1 1 0 0 0 0 0 0 0 0 0 X 13 13 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 0 IN X AMY CROUCH - CHIEF FINANCIAL OFFICER 2609254600 1316 E 7TH STREET AUBURN IN 46706 ALAN MIDDLETON 1.00 0.00 X X 0 0 0 ROBERT MENZIE 1.00 0.00 X X 0 0 0 RICHARD ALLEN 1.00 0.00 X X 0 0 0 DEB LINSTROMBERG 1.00 0.00 X 0 0 0 CAROLINE DERROW DDS 1.00 0.00 X 0 0 0 MATT FETTER 1.00 0.00 X 0 0 0 MARK FOGT 1.00 0.00 X 0 0 0 BETH FREIDENBERGER 1.00 0.00 X 0 0 0 JEFF JUSTICE MD 1.00 0.00 X 0 0 0 MARK MILLET 1.00 0.00 X 0 0 0 DOUGLAS MORROW OD 1.00 0.00 X 0 0 0 BRIAN NUGEN 1.00 0.00 X 0 0 0 MITCHELL TRAVIS MD 1.00 0.00 X 0 0 0 FRED PRICE 40.00 0.00 X 0 0 0 AMY CROUCH 40.00 0.00 X 145792 0 288 EMILIO VAZQUEZ 40.00 0.00 X 269795 0 12931 KENNETH CHAFFEE 40.00 0.00 X 301831 0 28759 BRET KUEBER 40.00 0.00 X 224374 0 28560 SCOTT ARMSTRONG 40.00 0.00 X 223404 0 34539 PHILIP CHASE 40.00 0.00 X 209187 0 14223 RICHARD TOUPIN 40.00 0.00 X 198252 0 14414 KIRK RAY 40.00 0.00 X 249832 0 26584 1822467 0 160298 24 1 1 0 ALLIED MEDICAL SERVICES 6444 MONROE STREET SUITE 201 SYLVANIA OH 43560 RT SERVICES 476065 EMERGENCY PHYSICIANS OF IN PC 4560 SOLUTIONS CENTER CHICAGO IL 60677 PHYSICIAN SERVICES 467137 APRN SLEEP INC 6444 MONROE STREET SUITE 5 SYLVANIA OH 43560 REFERENCE LAB 241497 PSI SUPPLY CHAIN SOLUTIONS LLC 5050 BRADENTON AVENUE DUBLIN OH 43017 SUPPLY SERVICES 187594 BKD LLP 200 E MAIN STREET SUITE 700 FORT WAYNE IN 46802 ACCOUNTING SERVICES 183873 6 103983 103983 PATIENT SERVICE REVENUE 623990 51132306 51132306 PHARMACARE 621500 4242933 4242933 FINANCIAL SERVICES 900099 1432301 1432301 CAFETERIA SALES 722320 277415 217358 60057 57084955 505539 505539 709433 258199 451234 451234 451234 4534111 4587909 -53798 -53798 -53798 CLEANING 812300 8155 8155 LAUNDRY 812300 1276 1276 180516 180516 189947 58281860 57656648 69488 451741 107509 107509 696147 342118 354029 22941487 21322074 1597024 22389 991184 911889 79295 5194342 5022869 157821 13652 1715801 1578537 137264 114288 114288 75703 11860 63843 123866 123866 5177442 4866214 311228 457970 73125 384845 1588070 1349902 236852 1316 1523305 1480920 42385 1021393 940657 80736 321058 285318 35737 3 52192 33645 18547 343044 343044 4873292 4585940 287352 590074 241743 348331 MEDICAL SUPPLIES 8163380 8163380 H.A.F. ASSESSMENT 2304619 2304619 LICENSE, ACCRED FEE & M 385626 73404 312222 COLLECTION FEES 332402 332402 38447 38447 59132641 54142413 4952868 37360 2750 104588 1235665 7325062 9422823 8294 626749 1324144 1399437 1040979 75806725 38263812 40357773 37542913 15392864 17207351 1390698 1177899 68069935 67490054 6077934 6609350 5351775 3763376 8331936 2443938 1409496 17637023 16350782 X 50324022 51137455 108890 1817 50432912 51139272 68069935 67490054 X -850781 1339837 217304 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 6116 6116 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: THE HOSPITAL PAID MEMBERSHIP DUES TO INDIANA HOSPITAL ASSOCIATION "IHA" AND AMERICAN HOSPITAL ASSOCIATION "AHA" IN ADDITION TO INDIANA ASSOCIATION FOR HOME & HOSPICE CARE "IAHHC". IHA ATTRIBUTED 5.26% ($1,224); AHA ATTRIBUTED 23.98% ($4,706); AND IAHHC ATTRIBUTED 12% ($186) OF THE DUES TO LOBBYING EXPENSES TO TOTAL $6,116 ABOVE. 108890 33375 34016 106432 1817 112897 76699 80706 108890 28679 84218 112897 0 28679 28679 1.00000 0 0 393118 393118 54425960 24604697 29821263 20880721 13659115 7221606 106926 106926 37542913 CAPITAL LEASE OBLIGATIONS 1397696 ESTIMATED THIRD PARTY SETTLEMENT 11800 1409496 60097200 1339837 475503 1815340 58281860 0 58281860 59390840 258199 258199 59132641 0 59132641 PART XI, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES REPORTED IN REVENUE 258,199. INCREASE IN INVESTMENT IN EQUITY INVESTEE 217,304. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES REPORTED IN REVENUE 258,199. PART X, LINE 2, FIN 48 FOOTNOTE: NOT APPLICABLE. THE AUDITED FINANCIAL STATEMENTS DID NOT INCLUDE A FOOTNOTE REGARDING UNCERTAIN TAX POSITIONS UNDER FIN 48. HOWEVER, MANAGEMENT HAS EVALUTAED THE INCOME TAX POSITIONS UNDER THIS GUIDANCE AND BASED ON REVIEW, MANAGEMENT HAS NOT IDENTIFIED ANY MATERIAL UNCERTAIN TAX POSITIONS TO BE REPORTED OR DISCLOSED ON THE AUDITED FINANCIAL STATEMENTS ENDING SEPTEMBER 30, 2013. 1 1 1 X 1 X 1 1 0 1 1 548241 548241 0.00930 8168405 3932712 4235693 0.07160 8716646 3932712 4783934 0.08090 93985 93985 0.00160 25000 25000 0.00040 30243 30243 0.00050 149228 149228 0.00250 8865874 3932712 4933162 0.08340 20459 20459 0.00030 36757 36757 0.00060 5000 5000 0.00010 24447 24447 0.00040 585 585 0.00000 87248 87248 0.00140 1 4443148 0 6688465 8279955 -1591490 X 1 1 1 1 DEKALB MEMORIAL HOSPITAL

1316 E 7TH STREET AUBURN IN 46706

X X X DEKALB MEMORIAL HOSPITAL INC 1 1 X X X X X X X X X 12 1 0 1 X X X X X X X X X X 1 0 1 1 200.000000000000 1 350.000000000000 1 X X X X X X 1 1 X X X X X 1 0 X X X X 1 X 0 0 PART I, LINE 3C: THE ORGANIZATION USES THE FEDERAL POVERTY GUIDELINES WHEN DETERMINING ELIGIBILITY FOR DISCOUNTED CARE BETWEEN 200% AND 350% OF THE FEDERAL POVERTY LIMIT (FPL) AS FOLLOWS: PATIENTS WITH INCOME BETWEEN 200% AND 250% OF THE FPL ARE ELIGIBLE FOR A 75% WRITE-OFF; PATIENTS WITH INCOME BETWEEN 250% AND 300% OF THE FPL ARE ELIGIBLE FOR A 50% WRITE-OFF; AND PATIENTS WITH INCOME BETWEEN 300% AND 350% OF THE FPT ARE ELIGIBLE FOR A 30% WRITE-OFF. PART II: COMMUNITY BUILDING ACTIVITIES.THE HOSPITAL GIVES BACK THROUGH FINANCIAL AND EDUCATIONAL EFFORTS AND THROUGH VOLUNTEERING, AWARENESS INITIATIVES AND SUPPORT GROUPS. SOME OF THE MANY COMMUNITY EDUCATION PROGRAMS FOR CHILDREN AND ADULTS INCLUDE: PRENATAL EDUCATION, ACLS, CPR, AND FIRST AID TRAINING, DIABETES EDUCATION, SMOKING CESSATION AND WEIGHT MANAGEMENT. SOME OF THE COMMUNITY OUTREACH ACTIVITIES INCLUDE INVOLVEMENT IN: COMMUNITY AND WORKPLACE HEALTH & WELLNESS FAIRS, PRESENTATIONS TO COMMUNITY GROUPS, SPORTS PHYSICALS, ORGAN DONATION, AND EMS STANDBY FOR MULTIPLE PUBLIC EVENTS. MANY OF THE PROGRAMS FINANCIALLY SUPPORTED PROVIDE INCREASED OPPORTUNITIES TO HELP PARTICIPANTS BE PHYSICALLY ACTIVE AND HEALTHY. PART III, LINE 4: SECTION A. BAD DEBT EXPENSE. METHOD FOR ESTIMATING BAD DEBT EXPENSE AMOUNT ON PART III, LINE 2: HOSPITAL MANAGEMENT ANALYZES PAST HISTORY AND IDENTIFIES TRENDS FOR EACH MAJOR PAYER SOURCE OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBT EXPENSE. ACCOUNTS ARE CONSIDERED DELINQUENT AND SUBSEQUENTLY WRITTEN OFF AS BAD DEBTS BASED ON INDIVIDUAL CREDIT EVALUATION AND SPECIFIC CIRCUMSTANCES OF THE ACCOUNT. AN AGGREGATE COST TO CHARGE RATIO WAS USED TO PROVIDE BAD DEBT AT COST. THE ESTIMATED AMOUNT OF THE HOSPITAL'S BAD DEBT EXPENSE (AT COST) ATTRIBUTABLE TO PATIENTS THAT MIGHT HAVE BEEN ELIGIBLE UNDER THE HOSPITAL'S CHARITY CARE POLICY WAS DETERMINED BY COMPUTING A PERCENTAGE OF DOLLAR AMOUNT TOTALS OF ACCOUNTS APPROVED FOR ASSISTANCE TO TOTAL APPLICATIONS AND THEN APPLIED THE PERCENTAGE TO THE APPLICATIONS THAT WERE DENIED DUE TO INCOMPLETE INFORMATION TO COME UP WITH AN ESTIMATE OF WHAT WOULD HAVE QUALIFIED IF THE INFORMATION HAD BEEN RECEIVED. THE RATIONALE BEING THAT HAD THE INFORMATION BEEN RECEIVED, THOSE ACCOUNTS WOULD HAVE BEEN APPROVED.EXPLANATION FOR RATIONAL FOR INCLUDING OTHER BAD DEBT AMOUNT IN COMMUNITY BENEFIT ON PART III, LINE 3: NO OTHER BAD DEBT AMOUNTS HAVE BEEN INCLUDED AS COMMUNITY BENEFIT. THE HOSPITAL HAS A DETAILED FINANCIAL ASSISTANCE POLICY. IN ADDITION, THE HOSPITAL EDUCATES PATIENTS WITH LIMITED ABILITY TO PAY REGARDING FINANCIAL ASSISTANCE. FOR THIS REASON, THE ORGANIZATION BELIEVES IT ACCURATELY CAPTURES ALL CHARITY CARE DEDUCTIONS PROVIDED ACCORDING TO THE FINANCIAL ASSISTANCE POLICY AND THE AMOUNT OF BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY IS NEGLIGIBLE. THE TEXT TO THE AUDITED FINANCIAL STATEMENT FOOTNOTE DESCRIBING BAD DEBT EXPENSE AND ITS PRESENTATION IS INCLUDED IN FOOTNOTE 1 "CHANGE IN ACCOUNTING PRINCIPLE" AND "PATIENT ACCOUNTS RECEIVABLE" ON PAGES 8 AND 9. PART III, LINE 8: THE SOURCE USED TO DETERMINE THE AMOUNT OF MEDICARE ALLOWABLE COSTS REPORTED FOR PART III, SECTION B, MEDICARE HAS BEEN PROVIDED FROM THE YEAR ENDED SEPTEMBER 30, 2013: HOSPITAL STATEMENT OF REIMBURSABLE COST PART III, LINE 9B: THE HOSPITAL'S COLLECTION PRACTICES FOR THOSE QUALIFYING FOR FINANCIAL ASSISTANCE INCLUDE: (1) DESIGNATING THE ACCOUNTS QUALIFYING FOR FINANCIAL ASSISTANCE IN THE ACCOUNTS RECEIVABLE SYSTEM AS CHARITY CARE; (2)EXCLUDING THE ACCOUNTS FROM BAD DEBT WRITE OFFS; AND (3) EXCLUDING THE ACCOUNTS FROM BEING REPORTED TO ANY COLLECTION AGENCIES. DEKALB MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 3: THE HOSPITAL FACILITY TOOK INTO ACCOUNT INPUT FROM PERSONS WHO REPRESENT THE COMMUNITY THROUGH COMMUNITY SURVEYS SENT TO HOUSEHOLDS IN DEKALB COUNTY, PROVIDER SURVEYS SENT, AND FEEDBACK COLLECTED FROM KEY CONSTITUENTS. DEKALB MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 4: THE ASSESSMENT WAS NOT CONDUCTED WITH OTHER HOSPITALS, BUT WAS PART OF A COLLABORATIVE EFFORT WITH DEKALB COUNTY HEALTH DEPT AND IPFW CENTER FOR SOCIAL RESEARCH. DEKALB MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 5C: THE COMMUNITY HEALTH NEEDS ASSESSMENT IS AVAILABLE AT WWW.DEKALBHEALTH.COM LOCATED UNDER THE DROP DOWN MENU "COMMUNITY". DEKALB MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 11: THE ORGANIZATION USES THE FEDERAL POVERTY GUIDELINES WHEN DETERMINING ELIGIBILITY FOR DISCOUNTED CARE BETWEEN 200% AND 350% OF THE FEDERAL POVERTY LIMIT (FPL) AS FOLLOWS: PATIENTS WITH INCOME BETWEEN 200% AND 250% OF THE FPL ARE ELIGIBLE FOR A 75% WRITE-OFF; PATIENTS WITH INCOME BETWEEN 250% AND 300% OF THE FPL ARE ELIGIBLE FOR A 50% WRITE-OFF; AND PATIENTS WITH INCOME BETWEEN 300% AND 350% OF THE FPT ARE ELIGIBLE FOR A 30% WRITE-OFF. PART VI, LINE 2: ASSESSING COMMUNITY NEED.THE HOSPITAL ASSESSES THE HEALTH CARE NEEDS OF THE COMMUNITY THROUGH PERIODIC FOCUS GROUP SURVEYS BY OUTSIDE CONSULTANTS WHICH ARE PREPARED EVERY 3 YEARS TO ASSESS THE NEEDS OF THE COMMUNITY. THESE SURVEYS INCLUDE INPUT FROM INDIVIDUALS, HEALTH PROFESSIONALS, GOVERNMENTAL HEALTH CARE OFFICIALS AS WELL AS REPRESENTATIVES FROM DEKALB HOSPITAL. THE SURVEY SOLICITS INPUT ON THE HEALTH CARE NEEDS INCLUDING OBESITY, PREVENTIVE MEDICINE, VACCINATIONS, CARDIOVASCULAR, ETC. THESE NEEDS AND CONCERNS ARE EVALUATED AND APPROPRIATE PLANS ARE PUT INTO ACTION TO DEAL WITH THE MOST PRESSING ISSUES. CUSTOMER SATISFACTION SURVEYS ARE ALSO USED TO IDENTIFY UNMET HEALTHCARE NEEDS OF THE COMMUNITY.RECENTLY, IN THE FALL OF 2012, IPFW CENTER FOR SOCIAL RESEARCH FINALIZED AND REPORTED ON THE COMMUNITY HEALTH NEEDS ASSESSMENT THEY CONDUCTED ON BEHALF OF THE DEKALB COUNTY HEALTH DEPARTMENT AND DEKALB HEALTH. THIS SURVEY IS A TOOL THE HOSPITAL IS USING AS ONE OF THE KEY COMPONENETS FOR COMMUNITY OUTREACH STRATEGIES. THIS SURVEY IN ADDITION TO FEEBACK RECEIVED FROM KEY CONSTITUENTS I.E. THE UNITED WAY OF DEKALB COUNTY, COMMUNITY FOUNDATION OF DEKALB COUNTY, CHILDREN FIRST CENTER, PURDUE EXTENSION OFFICE, SCHOOLS, PHYSICIAN OFFICES, HOSPITAL DEPARTMENT MANAGERS, AND OTHERS HELPED TO IDENTIFY THE HEALTH CARE NEEDS OF THE COMMUNITY. PART VI, LINE 3: PATIENT EDUCATION OF ASSISTANCE ELIGIBILITY.PATIENTS ARE PROVIDED INFORMATION REGARDING THE CHARITY CARE POLICIES WHEN ADMITTED TO DEKALB HOSPITAL. FINANCIAL AID GUIDELINES ARE ALSO INCLUDED WITH THE BILLING STATEMENTS. SIGNS OUTLINING THE FINANCIAL AID POLICIES AND APPLICATIONS ARE ALSO LOCATED IN NUMEROUS AREAS THROUGHOUT THE HOSPITAL. ALL NON-INSURED PATIENTS ARE STRONGLY ENCOURAGED TO MEET WITH A FINANCIAL COUNSELOR TO REVIEW ALL OPTIONS AVAILABLE TO THEM INCLUDING MEDICARE, MEDICAID, CHARITY CARE, LOAN AND PAYMENT PROGRAMS. DEKALB HOSPITAL STAFF WILLINGLY ASSIST PATIENTS WITH QUALIFICATION CRITERIA AND COMPLETION OF APPLICATIONS FOR SUCH PROGRAMS, WHERE APPLICABLE. PART VI, LINE 4: COMMUNITY DESCRIPTION.DEKALB MEMORIAL HOSPITAL IS THE SOLE COMMUNITY HOSPITAL LOCATED IN DEKALB COUNTY, SERVING DEKALB, PORTIONS OF STEUBEN, LAGRANGE, NOBLE, AND ALLEN COUNTIES IN ADDITION TO SEVERAL BORDER TOWNS OF HICKSVILLE AND EDGERTON IN NORTHWEST OHIO. THE PRIMARY SERVICE AREA POPULATION OF DEKALB MEMORIAL HOSPITAL IS APPROXIMATELY 42,000 WITH APPROXIMATELY 98% RECORDED AS WHITE. DEKALB HAS SEEN AN INCREASE IN THE UNINSURED AND UNDERINSURED WITH A REPORTED AMOUNT OF 12.1% OF RESIDENTS LIVING BELOW THE POVERTY LEVEL. THE DEMOGRAPHIC AREA SERVED BY DEKALB MEMORIAL HOSPITAL IS MADE UP OF A MEDIAN HOUSEHOLD INCOME OF APPROXIMATELY $46,000, THE MEDIAN AGE IS 38 AND CONTAINS PRIMARILY A BLUE COLLAR AND AGRICULTURAL WORKFORCE. PART VI, LINE 5: COMMUNITY HEALTH PROMOTION.THE ORGANIZATION FURTHERS ITS EXEMPT PURPOSE BY PROMOTING HEALTH OF THE COMMUNITY THROUGH THE FOLLOWING: AN OPEN MEDICAL STAFF, CORPORATE BOARD MADE UP OF 30 COMMUNITY MEMBERS THAT SELECT THE BOARD OF DIRECTORS, AND THE USE OF SURPLUS FUNDS TO PROVIDE HIGH QUALITY HEALTHCARE SERVICES TO THE CITIZENS RESIDING IN ITS SERVICE AREAIN ADDITION, MANY OF THE HOSPITAL'S MANAGERS AND STAFF DONATE THEIR TIME TO SUPPORT ST. MARTIN'S HEALTHCARE CLINIC (FOR UNINSURED) AS WELL AS SERVE ON UNITED WAY, CHAMBER OF COMMERCE, ECONOMIC DEVELOPMENT BOARDS, AND JUNIOR ACHIEVEMENT. NONPERISHABLE FOOD ITEMS THAT ARE LEFT OVER AFTER THE HEATLHY HALLOWEEN FAIR AND/OR PLAY-LEARN-SOAR ARE DONATED TO A LOCAL FOOD BANK OR BOOMERANG BACKPACK PROGRAM. PART VI, LINE 6: AFFILIATED HEALTH CARE SYSTEM.THE ORGANIZATNION IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM. REPORTS FILED WITH STATES PART VI, LINE 7 IN 1 DEKALB HEALTH COMMUNITY FOUNDATION 212 WEST 7TH STREET AUBURN IN 46706 356047817 501C3 44359 PROGRAM SUPPORT FORT WAYNE MEDICAL EDUCATION PROGRAM 50 BROADWAY FORT WAYNE IN 46802 356049685 501C3 25000 PROGRAM SUPPORT DEKALB COUNTY ECONOMIC DEVELOPMENT PARTNERS 4483 COUNTY ROAD 19 AUBURN IN 46706 364577514 501C3 10000 COMMUNITY SUPPORT NORTHEAST INDIANA REGIONAL PARTNERSHIP 200 E MAIN STREET FORT WAYNE IN 46802 351984702 501C6 10000 PROGRAM SUPPORT KRAMER ENTERTAINMENT 3849 LAKE MICHIGAN DRIVE NW GRAND RAPIDS IN 49534 453972742 8150 DISTRACTED DRIVING PROGRAM FORT WAYNE MAD ANTS 1910 ST JOE CENTER ROAD FORT WAYNE IN 46825 208684500 5000 FITNESS PROGRAM DEKALB ALUMNI FUND 3424 CR 427 WATERLOO IN 46793 351097343 5000 STUDENT LEADERSHIP PROGRAM 3 4 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: THE AMOUNT OF ASSISTANCE LISTED IN PART II ARE GENERAL CONTRIBUTIONS FOR GENERAL PROGRAM SUPPORT. THE HOSPITAL DOES NOT MONITOR THE USE OF FUNDS ONCE DISTRIBUTED TO THESE ORGANIZATIONS. 0 0 0 0 0 0 0 0 0 EMILIO VAZQUEZ 192456 0 59904 0 17435 0 12931 0 0 0 282726 0 0 0 KENNETH CHAFFEE 295597 0 0 0 6234 0 15000 0 13759 0 330590 0 0 0 BRET KUEBER 177868 0 34055 0 12451 0 10452 0 18108 0 252934 0 0 0 SCOTT ARMSTRONG 209917 0 0 0 13487 0 11419 0 23120 0 257943 0 0 0 PHILIP CHASE 191232 0 0 0 17955 0 0 0 14223 0 223410 0 0 0 RICHARD TOUPIN 181454 0 0 0 16798 0 0 0 14414 0 212666 0 0 0 KIRK RAY 223788 0 0 0 26044 0 8191 0 18393 0 276416 0 0 0 SCOTT ARMSTRONG PART V PART V X 20000 8294 0 1 1 8294 SCHEDULE L, PART II, LOAN TO/ FROM INTERESTED PERSONS: (A) NAME OF PERSION: SCOTT ARMSTRONG(B) RELATIONSHIP WITH ORGANIZATION: HIGHEST COMPENSATED EMPLOYEE(C) PURPOSE OF LOAN: PHYSICIAN RECRUITMENT LOAN FORM 990, PART I, DOING BUSINESS AS: DEKALB HEALTH DEKALB HEALTH HOME CARE DEKALB HEALTH HOSPICE DEKALB HEALTH MEDICAL GROUP DEKALB HEALTH MEDICAL GROUP - BUTLER DEKALB HEALTH MEDICAL GROUP - GARRETT DEKALB HEALTH MEDICAL GROUP - ARMSTRONG DEKALB HEALTH MEDICAL GROUP - PEDIATRICS FORM 990, PART VI, SECTION A, LINE 6 THE ORGANIZATION HAS CORPORATE BOARD MEMBERS CONSISTING OF 30 COMMUNITY MEMBERS. FORM 990, PART VI, SECTION A, LINE 7A THE ORANIZATION HAS CORPORATE BOARD MEMBERS CONSISTING OF 30 COMMUNITY MEMBERS. FOURTEEN MEMBERS WERE ELECTED BY THE CORPORATE BOARD AND SERVED AS THE ORGANIZATIONS GOVERNING BODY DURING FISCAL YEAR 2013. FORM 990, PART VI, SECTION A, LINE 7B NOMINATIONS AND APPROVAL FOR VACANCIES ON THE GOVERNING BOARD ARE SUBJECT TO APPROVAL BY CORPORATE MEMBERS. ALL BUSINESS DECISIONS OF THE GOVERNING BODY ARE RATIFIED BY ANNUAL RESOLUTION OF THE CORPORATE BOARD. FORM 990, PART VI, SECTION B, LINE 11 THE 990 PROCESS INCLUDES A DETAIL REVIEW BY THE ACCOUNTING MANAGER, CHIEF FINANCIAL OFFICER AND CHIEF EXECUTIVE OFFICER. A COPY OF THE FORM 990 IS PROVIDED TO THE AUDIT AND FINANCE COMMITTEE FOR REVIEW. A REPORT OF THE COMMITTEE'S REVIEW AND COPY OF THE FORM 990 INCLUDING REQUESTED SCHEDULES, AS ULTIMATELY FILED WITH THE IRS, ARE PROVIDED TO THE BOARD OF DIRECTORS PRIOR TO FILING WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C THE CONFLICT OF INTEREST STATEMENTS ARE COMPLETED ANNUALLY BY ALL BOARD MEMBERS AND STAFF. THE ANNUAL STATEMENTS ARE REVIEWED BY THE BOARD CHAIR. WHEN CONDUCTING ORGANIZATION BUSINESS AND A CONFLICT ARISES, THE BOARD OR STAFF MEMBER INVOLVED ABSTAINS FROM VOTING ON RELATED MATTERS. DOCUMENTATION ON THIS MATTER IS KEPT IN THE BOARD MINUTES. FORM 990, PART VI, SECTION B, LINE 15 AN INDEPENDENT COMPENSATION COMMITTEE, A SUB-COMMITTEE OF THE BOARD, REVIEWS AND APPROVES THE COMPENSATION OF THE CHIEF EXECUTIVE OFFICER, CHIEF FINANCIAL OFFICER AND OTHER KEY EMPLOYEES; THIRD PARTY AND MARKET DATA ARE UTILIZED AS COMPARABLE DATA; AND, DELIBERATION OF THESE DECISIONS ARE DOCUMENTED IN THE COMMITTEE'S MINUTES. FORM 990, PART VI, SECTION C, LINE 19 THE CONFLICT OF INTEREST POLICY, GOVERNING DOCUMENTS, AND FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST. IN ADDITION, THE ARTICLES OF INCORPORATION CAN BE VIEWED ON THE WEBSITE FOR THE INDIANA SECRETARY OF STATE AND THE MOST CURRENT FINANCIAL STATEMENTS ARE ATTACHED TO THIS FORM 990. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: GAIN ON INVESTMENT IN EQUITY INVESTEE 217,304. OVERSIGHT OF AUDIT FORM 990, PART XII, LINE 2C THE AUDIT COMMITTEE ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF THE FINANCIAL STATEMENTS AND SELECTION OF THE INDEPENDENT ACCOUNTANT; AND NO PROCESSES HAVE CHANGED FROM PRIOR YEAR. DEKALB MEMORIAL PHARMACARE LLC 1314 E 7TH STREET AUBURN IN 46706 273514342 RETAIL PHARMACY IN 280297 668506 DEKALB MEMORIAL HOSPITAL DEKALB COMM HOSPITAL FOUNDATION 212 WEST 7TH STREET AUBURN IN 46706 356047817 FOUNDATION IN 501(C)3 LINE 11 DEKALB MEMORIAL HOSPITAL 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0