2014-05-15T14:03:07-05:00 2013-06-30 BKD LLP 2800 Post Oak Blvd Ste 3200 HOUSTON TX 77056 990 2012-07-01 751976930 MOTHER FRANCES HOSPITAL - JACKSONVILLE % MFH ACCOUNTING DEPARTMENT MOTH 9035315764 1315 DOCTORS DRIVE Suite TYLER TX 75701 JOYCE HESTER 9035314542 2014-05-15 true Amanda Maya 7134994600 2012 2015-11-30 17:44:51Z RAY THOMPSON 910 E HOUSTON SUITE 500 TYLER TX 75702 40099579 false X WWW.TMFHS.ORG/JACKSONVILLE X 2000 TX TO PROVIDE THE COMMUNITY WITH A FULL RANGE OF COMPREHENSIVE HEALTHCARE SERVICES WITHOUT REGARD TO RACE, CREED, SEX, NATIONAL ORIGIN, HANDICAP, AGE, OR ABILITY TO PAY. 7 3 179 3 0 0 0 5109 37803399 40092036 0 0 10 2434 37803409 40099579 1010437 1133785 0 0 9802949 10110064 0 0 0 25418456 27225733 36231842 38469582 1571567 1629997 34548586 18821914 20466348 3109679 14082238 15712235 TO PROVIDE THE COMMUNITY WITH A FULL RANGE OF COMPREHENSIVE HEALTHCARE SERVICES WITHOUT REGARD TO RACE, CREED, SEX, NATIONAL ORIGIN, HANDICAP, AGE, OR ABILITY TO PAY. false false 33435852 1133785 40092036 THE HOSPITAL'S OPERATING PLAN INCORPORATES PROVISIONS FOR INDIVIDUALS WHO DO NOT POSSESS THE ABILITY TO PURCHASE ESSENTIAL MEDICAL SERVICES. OUR COMMITMENT TO OUR COMMUNITY EXTENDS TO FREE OR SUBSIDIZED INDIVIDUAL CARE, SUBSIDIZED EDUCATION OF HEALTHCARE PROFESSIONALS, DISCOUNTED FEES FOR PARTICIPANTS IN GOVERNMENT PROGRAMS, COMMUNITY HEALTH EDUCATION AND DONATIONS TO OTHER COMMUNITY AGENCIES. SPECIFIC COMMUNITY SERVICES AND PROGRAMS INCLUDE: WELLNESS AND PREVENTION EDUCATION PROGRAMS, COMMUNITY DIAGNOSTIC SCREENING PROGRAMS, SENIOR CITIZEN HEALTH AWARENESS PROGRAMS, AWARENESS PROGRAMS FOR YOUTH AT RISK, AND AWARENESS PROGRAMS FOR PERSONS WITH SPECIAL PHYSICAL OR MENTAL NEEDS. 33435852 true false false true false false false false false false true false false true true false false true false false false false false false false false true true true false true false false false false false false false false false false false false false true false false false true X 34 0 true 179 true false false false false false false false false false false X 7 3 false false false false true true true true true false false true true true true true true true true false X MFH ACCOUNTING DEPARTMENT 9035315764 1315 DOCTORS DRIVE TYLER TX 75701 X THOMAS N CAMMACK JR 40.0 0.0 X X 273507 0 20707 MATTHEW A VIERKANT MD 10.0 30.0 X 0 497339 13125 RAY THOMPSON 1.0 42.0 X X 221425 1360188 21049 GLEN T HAMILTON 10.0 0.0 X X 0 0 0 WILLIAM MILAWSKI MD 40.0 0.0 X 0 257372 13025 DICK STONE 1.0 1.0 X 0 0 0 RANDY GORHAM 1.0 X 0 0 0 J LINDSEY BRADLEY JR 1.0 42.0 X 34500 1690480 21049 MICHAEL LEWIS 40.0 0.0 X 131213 0 20719 JOYCE HESTER 5.0 37.0 X 54214 397573 14147 KLEANTHE CARUSO 40.0 0.0 X 121167 0 4407 BARRY L THIBODEAUX 40.0 0.0 X 247825 0 9388 JACK CAPPS 40.0 0.0 X 241330 0 26047 BEN BEATHARD 40.0 0.0 X 115398 0 21205 MICHAEL BENTOSKI 40.0 0.0 X 107105 0 16014 1547684 4202952 200882 8 false true false COMPLETE RX LTD 3100 S GESSNER RD HOUSTON TX 77063 PHARMACY SERVICES 759328 CARDIAC IMAGING SERVICES 1737 DOMINION PLAZA TYLER TX 75703 IMAGING SERVICES 229663 CAPSTONE PERSONNEL SERVICES INC PO BOX 5744 TYLER TX 75711 CONTRACT STAFFING 191005 3 5109 5109 NET PATIENT REVENUE 621110 36002176 36002176 UPL MEDICAID REVENUE 900099 1800942 1800942 EHR INCENTIVE REVENUE 900099 886977 886977 PHARMACY REVENUE 446110 1277801 1277801 RELATED RENTAL REVENUE 532000 104685 104685 19455 19455 40092036 0 0 0 0 0 0 0 0 0 0 REBATE INCOME 900099 2434 2434 2434 40099579 40092036 2434 X 1133785 1133785 0 0 0 1454340 1211916 242424 0 6764626 5611050 1153576 205862 183217 22645 1128364 1004244 124120 556872 495616 61256 81433 81433 0 0 0 0 0 12701608 12335378 366230 24725 24725 116603 46591 70012 26213 11095 15118 0 2697308 420781 2276527 6905 6160 745 0 6221 5929 292 0 0 491933 491933 40477 40477 BAD DEBT EXPENSE 7573744 7573744 MEDICAL SUPPLIES 2651055 2620381 30674 FOOD 113048 109130 3918 REPAIRS AND MAINTENANCE 576931 572815 4116 117529 94020 23509 38469582 33435852 5033730 0 38333 -302033 0 0 0 0 4588047 7096065 0 0 0 0 0 0 170953 147465 197308 74805 6557575 5087612 1440472 1469963 0 0 0 0 0 0 0 0 28113473 10335649 34548586 18821914 2137460 1919135 0 0 0 0 0 0 0 0 0 0 0 0 0 0 18328888 1190544 20466348 3109679 X 14082238 15712235 0 0 0 0 14082238 15712235 34548586 18821914 1629997 X false true X true false X false false false false false true 1873 false false false 1873 false grants for lobbying purposes SCHEDULE C, PART II-B, LINE 1F 23.98% of AHA dues were expended for specific lobbying purposes based on Medicare definition of unallowable expenses. 6557575 5087612 1469963 1469963 DUE FROM AFFILIATES 10335649 10335649 0 THIRD PARTY PAYOR LIABILITIES 911844 ESTIMATED SELF INSURANCE COSTS 278700 1190544 32524080 -7573744 -7573744 40097824 1755 1755 40099579 30894083 -1755 -1755 30895838 7573744 7573744 38469582 REVENUE INCLUDED ON BOOKS, NOT ON RETURN: SCHEDULE D, PART XI, LINE 2D BAD DEBT EXPENSE IN AUDIT REVENUE ($7,573,744) REVENUE INCLUDED ON RETURN, NOT ON BOOKS: SCHEDULE D, PART XI, LINE 4B REBATES IN AUDIT EXPENSE $ 1,755 EXPENSES INCLUDED ON BOOKS, NOT ON RETURN: SCHEDULE D, PART XII, LINE 2D REBATES IN AUDIT EXPENSE ($ 1,755) EXPENSES INCLUDED ON RETURN, NOT ON BOOKS: SCHEDULE D, PART XII, LINE 4B BAD DEBT EXPENSE IN AUDIT REVENUE $7,573,744 true true X true X true X true true true false true true 1387960 1387960 0.04490 3784276 4988848 -1204572 0.00000 1880516 1037954 842562 0.02730 7052752 6026802 1025950 0.07220 7237 7237 0.00020 601690 601690 0.01950 1133785 1133785 0.03670 1742712 1742712 0.05640 8795464 6026802 2768662 0.12860 false 7573744 11943766 11363196 580570 X true true 1 1 MOTHER FRANCES HOSPITAL-JACKSONVILLE

1026 JACKSON STREET JACKSONVILLE TX 75766

X X X X MOTHER FRANCES HOSPITAL-JACKSONVILLE 1 true X X X X X X X X X 12 true false true X X X X false false true true 200. true 200. true X true true X X true false X X X true X false false BAD DEBT EXPENSE SCHEDULE H, PART III, SECTION A, LINE 2 THE AMOUNT REPORTED ON LINE 2 IS BAD DEBT EXPENSE PER THE AUDITED FINANCIAL STATEMENTS. COSTING METHODOLOGY SCHEDULE H, PART III, SECTION B, LINE 8 THE MEDICAL CENTER USES MEDICARE COST REPORT METHODOLOGY, WHICH APPORTIONS ROUTINE COSTS (ROOM AND BOARD) BASED ON MEDICARE OR MEDICAID DAYS TO TOTAL DAYS AND APPORTIONS ANCILLARY COSTS BASED ON PROGRAM CHARGES TO TOTAL CHARGES. COLLECTION POLICY SCHEDULE H, PART III, SECTION C, LINE 9B THE ORGANIZATION HAS A WRITTEN POLICY COVERING PROCEDURES FOR COLLECTING AND WRITING OFF BAD DEBTS. ACCORDING TO THE POLICY, IF A PATIENT APPEARS TO BE INDIGENT, ACCOUNTS SHOULD BE REVIEWED, AT ANY TIME DURING THE COLLECTION PROCESS, FOR POSSIBLE CONSIDERATION AS A CHARITY CASE IN ACCORDANCE WITH THE ORGANIZATION'S CHARITY CARE POLICY. NEEDS ASSESSMENT SCHEDULE H, PART VI, LINE 2 THE HOSPITAL'S COMMUNITY HEALTH PROFILES PROVIDE A SNAPSHOT OF SUBURBAN, URBAN, AND RURAL SERVICE AREAS WITHIN TEXAS USING KEY HEALTH INDICATORS, WHICH FACILITATE COMPARISONS LOCALLY, REGIONALLY, AND OVER TIME. COMMUNITY HEALTH PROFILES ARE INTENDED TO ASSIST INTERNAL STAKEHOLDERS, COMMUNITY HEALTH COUNCIL MEMBERS, AND THE COMMUNITY HEALTH IMPROVEMENT DEPARTMENT IN DECIDING WHERE TO ALLOCATE RESOURCES AND ADDRESS HEALTH INEQUALITIES. ALL ENTITY ADVOCATES USE NATIONAL, STATE, AND LOCAL SECONDARY AND PRIMARY DATA SOURCES TO PROVIDE A CURRENT OVERVIEW OF LOCAL HEALTH NEEDS, FACTORS IMPACTING DISEASE AND INJURY BURDEN, SOCIOECONOMIC STATUS, ACCESS TO HEALTH CARE, AGE DISTRIBUTION, INDICATORS AND LIFESTYLE BEHAVIORS. THIS DATA IS USED TO GALVANIZE JOINT COMMUNITY HEALTH EFFORTS TO IMPROVE HEALTH AND REDUCE HEALTH INEQUALITIES AND TO EMPOWER THE GREATER COMMUNITY. PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE SCHEDULE H, PART VI, LINE 3 THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY AND CONTACT INFORMATION IS POSTED IN VARIOUS AREAS OF THE HOSPITAL INCLUDING ADMISSIONS & REGISTRATION, EMERGENCY, AND OUTPATIENT DEPARTMENTS. ADDITIONALLY, FINANCIAL ASSISTANCE INFORMATION IS PROVIDED, VERBALLY AND IN WRITTEN BROCHURES, TO ALL SELF PAY PATIENTS BY FINANCIAL COUNSELORS. FINANCIAL ASSISTANCE INFORMATION IS ALSO INCLUDED IN EVERY PATIENT BILL. THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY IS COMMUNICATED TO THE PATIENT BY FINANCIAL COUNSELORS WHO ALSO SCREEN SELF PAY PATIENTS FOR POTENTIAL ELIGIBILITY FOR OTHER GOVERNMENTAL ASSISTANCE PROGRAMS. IF IT IS DETERMINED THAT THE PATIENT IS POTENTIALLY ELIGIBLE FOR GOVERNMENTAL ASSISTANCE, THE FINANCIAL COUNSELOR WILL ASSIST THE PATIENT IN COMPLETING ANY FORMS NECESSARY TO APPLY FOR THE ASSISTANCE. AT THE SAME TIME, THE PATIENTS ARE PROVIDED WITH A CHARITY CARE APPLICATION AND INFORMATIONAL FLYER. THE PATIENT IS INFORMED THAT MOTHER FRANCES HOSPITAL-JACKSONVILLE IS A NON-PROFIT CHARITABLE ORGANIZATION OFFERING FINANCIAL ASSISTANCE TO PATIENTS WHO ARE DEEMED MEDICALLY OR FINANCIALLY INDIGENT. THE FINANCIAL COUNSELORS WILL THEN ASSIST THE PATIENT IN COMPLETING THE CHARITY CARE APPLICATION AND OBTAIN ANY AVAILABLE VERIFICATIONS. ONCE THE PATIENT IS DISCHARGED, THE FINANCIAL COUNSELORS WILL CONTINUE TO CONTACT THE PATIENT TO ENSURE ALL NEEDED FORMS AND VERIFICATIONS NEEDED TO FILE AN APPLICATION FOR GOVERNMENTAL ASSISTANCE AND CHARITY CARE HAVE BEEN PROVIDED. COMMUNITY INFORMATION SCHEDULE H, PART VI, LINE 4 MOTHER FRANCES HOSPITAL-JACKSONVILLE IS A 25-BED ACUTE CARE MEDICARE CERTIFIED CRITICAL ACCESS HOSPITAL. CHEROKEE COUNTY, THE PRIMARY SERVICE AREA FOR MFH-JACKSONVILLE, HAS A POPULATION OF APPROXIMATELY 57,000 AND IS PRIMARILY 48,000 IN A 1,052 SQUARE MILE AREA. THE SECONDARY SERVICE AREA INCLUDES THE SOUTHERN PART OF SMITH COUNTY. PROMOTION OF COMMUNITY HEALTH SCHEDULE H, PART VI, LINE 5 MOTHER FRANCES HOSPITAL-JACKSONVILLE PROMOTES HEALTHCARE AND WELLNESS EDUCATION BY OFFERING OUTREACH PROGRAMS AND SPECIAL INITIATIVES THAT IMPROVE THE QUALITY OF LIFE AND HEALTH IN THE COMMUNITIES SERVED. COMMUNITY BENEFIT IS PROVIDED THROUGH MANY REDUCED PRICE SERVICES AND FREE PROGRAMS TO THE COMMUNITY. THESE SERVICES ARE ESSENTIAL TO PROVIDE COMPLETE HEALTHCARE TO THE COMMUNITIES SERVED, SOME OF THESE PROGRAMS INCLUDE THE FOLLOWING: CHEROKEE COUNTY RELAY FOR LIFE - Provided sponsorship and staffing support for Cherokee County Relay for Life. Staff planned activities for the all - night event and manned the event. THE PURPOSE IS To increase awareness about cancer and to help in fundraising efforts for a county that has an above average rate of cancer. Educational programs targeted the community at large but efforts were made to reach the uninsured. JACKSONVILLE CHAMBER OF COMMERCE - JOB SHADOWING - Over 40 students participated in job shadowing projects and heard from health care professionals about their jobs. They spent time in the areas to see firsthand what the jobs entailed. THE PURPOSE IS To provide young high school students the opportunity to learn more about health care professionals and the healthcare work environment. Information was given on job opportunities and projected shortages of workers. JACKSONVILLE RODEO - Handed out fans and water to participants and spectators at the rodeo. Provided volunteers to interact on issues for 3 hours each of 4 nights. MFH jacksonville received an annual sponsorship to assist with the program. THE PURPOSE IS TO help educate participants about the dangers of heat and injuries caused by extensive heat. Reached over 1,000 people with heat prevention information and medical support on site. JACKSONVILLE ROTARY, ACCESS, AND OTHERS - Provided sponsorship, staffing, and development of programs and events for the local community. Organizations included Lions Club, Rotary, Kiwanis, Access, Hope Center, United Fund, American Cancer Society, Jacksonville Chamber of Commerce, and Jacksonville Literacy Council. Members of the staff serve in leadership positions and as volunteers for programs on various boards and non profits in the community. These programs benefit the residents of the area and organizations that provide services which are not provided by the hospital but impact the health of the residents in Anderson/Cherokee Counties. Finding leadership talent for volunteer positions is an ever growing problem for all communities. Target population for these services is the general public. HEALTH EDUCATION PROGRAMS - Community education for healthy life styles were offered throughout the region for a variety of conditions including cancer, cholesterol, diabetes, smoking cessation, stress, weight management, and healthy hearts. Over 1,000 people were reached. East Texas has an extremely high rate for diabetes, stroke, heart disease, and pulmonary disease. This east Texas region of the state has one of the fastest growing aging groups and high risk for ethnic minorities; both were targeted. COMMUNITY NON PROFITS AND RURAL HOSPITAL SUPPORT PROGRAMS - Mother Frances Hospital - Jacksonville provides direct financial support to not-for-profit organizations and community supported rural hospitals within the region to help provide needed services to the community. Priority is given to agencies or organizations that provide support or direct health related services or benefits and have a mission to serve the underinsured and uninsured. New programs included are Cherokee Health Advisory Board and EMS, Fire Department and Public Safety offices. These organizations or agencies provide services that otherwise would have to be provided by Mother Frances Hospital - Jacksonville or could be preventing patients from entering our facilities, particularly the emergency room. Many provide physician services, education or research programs which are not available at MFH - J or it may be too far for their patients to travel to receive services at our primary facilities. COMMUNITY LEADERSHIP PROGRAMS - Mother Frances Hospital-Jacksonville and the senior management team host and serve on key boards that encourage, and train leaders for the community. These boards also have the potential to direct and raise the awareness of healthcare needs of the area. The support and participation in these programs is to assist and lead in developing the future leaders of the community and region and to help them understand the crisis of access to health care in the region and the influence of governmental officials on healthcare services. COMMUNITY DISASTER PREPAREDNESS - Mother Frances Hospital- Jacksonville participated in the countywide disaster drill. It required staff to leave their regular job tasks and take on a community need and interact with law enforcement, fire departments, governmental agencies and EMS services. Over 500 people participated. The goal of the drill was to ensure community safety and readiness in the event a disaster occurs that requires direct or indirect medical services. How patients would appear and be triaged as well as transferred or admitted was included. FUNDRAISING FOR NOT-FOR-PROFITS - MFH-Jacksonville supports the United Fund Drive with an in-house program as well as Children's Miracle Network by raising money through direct financial donations, bake sales, jean days, special lunch offerings, etc. The goal is to raise money for services that otherwise would not be available for the community unless these monies were raised. The programs often target those less fortunate or have open door policies for all those who need the care. Additionally, these programs provide new leadership opportunities for the staff. AFFILIATED HEALTH CARE SYSTEM SCHEDULE H, PART VI, LINE 6 MOTHER FRANCES HOSPITAL - JACKSONVILLE IS PART OF AN AFFILIATED HEALTH CARE SYSTEM CALLED TRINITY MOTHER FRANCES HEALTH SYSTEM. TRINITY MOTHER FRANCES IS A FAITH-BASED ORGANIZATION DEDICATED TO CREATING HEALTHY LIVES FOR PEOPLE AND COMMUNITIES. MFH-JACKSONVILLE AND ITS AFFILIATES PROMOTE THE HEALTH OF THE COMMUNITIES SERVED BY PROVIDING ACUTE CARE FACILITIES AND CRITICAL ACCESS FACILITIES, WHOSE OPERATIONS CONSIST PRIMARILY OF PROVIDING INPATIENT AND OUTPATIENT ACUTE CARE AND MEDICAL SERVICES TO PATIENTS RESIDING IN EAST TEXAS. PERCENT OF TOTAL EXPENSE SCHEDULE H, PART I, LINE 7, COLUMN F TO ARRIVE AT THE PERCENT OF TOTAL EXPENSES, THE DENOMINATOR WHICH EQUALS TOTAL OPERATING EXPENSES PER PART IX, LINE 25, OF THE FORM 990 WAS REDUCED BY BAD DEBT EXPENSE, TOTALING $7,573,744. BILLING AND COLLECTIONS SCHEDULE H, PART V, LINES 16, 17, & 18 NEITHER MOTHER FRANCES HOSPITAL - JACKSONVILLE, NOR THIRD PARTIES AUTHORIZED BY MFH-J, TAKE ANY ACTIONS UPON NON-PAYMENT FROM A PATIENT BEFORE MAKING A REASONABLE EFFORT TO DETERMINE IF THE PATIENT IS ELIGIBLE FOR THE FACILITY'S FINANCIAL ASSISTANCE POLICY. STATE OF FILING COMMUNITY BENEFIT REPORT SCHEDULE H, PART VI, LINE 7 TEXAS NEEDS IDENTIFIED IN CHNA NOT ADDRESSED SCHEDULE H, PART V, SECTION B, LINE 7 MOTHER FRANCES HOSPITAL - JACKSONVILLE DECIDED NOT TO SPECIFICALLY ADDRESS THE NEED FOR "ACCESS TO DENTAL SERVICES," LARGELY DUE TO ITS POSITION (LAST) ON THE PRIORITIZED LIST AND THE HOSPITAL'S CAPACITY TO ADDRESS THAT NEED. DENTAL SERVICES ARE NOT A CORE BUSINESS FUNCTION OF THE HOSPITAL AND THE LEADERSHIP TEAM FELT THAT RESOURCES AND EFFORTS WOULD BE BETTER SPENT ADDRESSING THE FIRST SIX PRIORITIZED NEEDS. FURTHERMORE, AT LEAST ONE LOCAL DENTAL PROVIDER ACCEPTS MEDICAID AND CHIP. REPRESENTATIVES FROM THE COMMUNITY SCHEDULE H, PART V, SECTION B, LINE 3 MOTHER FRANCES HOSPITAL - JACKSONVILLE CONDUCTED 8 INTERVIEWS WITH THE THREE GROUPS OUTLINED IN IRS NOTICE 2011-52. DURING THESE INTERVIEWS THE HOSPITAL DISCUSSED THE HEALTH NEEDS OF THE COMMUNITY, ACCESS ISSUES, BARRIERS AND ISSUES RELATED TO SPECIFIC POPULATIONS. THE INTERVIEWEES WERE INDIVIDUALS FROM THE FOLLOWING GROUPS: BEN AND MAYTEE FISCH FOUNDATION, SENIOR CARE JACKSONVILLE, TEXAS DEPARTMENT OF STATE HEALTH SERVICES, ETCOG AREA AGENCY ON AGING, CHEROKEE COUNTY FAMILY SERVICES BOARD, NORTHEAST TEXAS PUBLIC HEALTH DISTRICT, UNITED FUND OF CHEROKEE COUNTY, AND CHEROKEE COUNTY PUBLIC HEALTH DEPARTMENT. BAD DEBT AS COMMUNITY BENEFIT SCHEDULE H, PART III, SECTION A, LINE 3 THE ORGANIZATION IS UNABLE TO ESTIMATE THE AMOUNT FOR LINE 3 AND HAS ELECTED TO LEAVE IT BLANK. BAD DEBT EXPENSE SHOULD BE CONSIDERED COMMUNITY BENEFIT BECAUSE THIS IS UNCOMPENSATED HEALTHCARE PROVIDED TO RESIDENTS OF THE COMMUNITY. FOOTNOTE TO THE FINANCIAL STATEMENTS DESCRIBING BAD DEBT EXPENSE SCHEDULE H, PART III, SECTION A, LINE 4 ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS. IN EVALUATING THE COLLECTABILITY OF ACCOUNTS RECEIVABLE, THE HEALTH SYSTEM ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYER SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND THE 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 HEALTH SYSTEM 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). true SERVICE ORGANIZATION OF PINEY WOODS 2950 50TH STREET LUBBOCK TX 79314 300630886 501(C)(3) 993310 COMMUNITY HEALTHCARE SERVICE ORGANIZATION OF NORTH EAST TEXAS 2950 50TH STREET LUBBOCK TX 79314 260468622 501(C)(3) 140475 COMMUNITY HEALTHCARE 2 PROCEDURES FOR MONITORING THE USE OF GRANT FUNDS IN THE U.S. SCHEDULE I, PART I, LINE 2 GRANT RECIPIENTS ARE REQUIRED TO ACKNOWLEDGE PRIOR TO THE ISSUANCE OF GRANT FUNDS THAT THE GRANT WILL BE USED IN ACCORDANCE WITH THE STATED PURPOSE OF THE GRANT APPLICATION AND ANY UNUSED FUNDS RELATED TO THE SPECIFIC PURPOSE OF THE GRANT WILL BE RETURNED TO THE ORGANIZATION. THE ORGANIZATION MONITORS AND REVIEWS THE FINANCIAL DATA OF RECIPIENTS TO ENSURE THAT THE GRANTED FUNDS ARE BEING USED PROPERLY. X true false X X X X X false true false false false false false false false THOMAS N CAMMACK JR 226210 0 35297 0 12000 0 9329 0 11378 0 294214 0 0 0 MATTHEW A VIERKANT MD 0 321208 0 167487 0 8644 0 10625 0 2500 0 510464 0 0 RAY THOMPSON 101011 620498 46462 285410 73952 454280 1487 9138 1459 8965 224371 1378291 73952 454280 WILLIAM MILAWSKI MD 0 175678 0 73945 0 7749 0 10625 0 2400 0 270397 0 0 J LINDSEY BRADLEY JR 17075 836657 17425 853823 0 0 212 10413 208 10216 34920 1711109 0 0 MICHAEL LEWIS 130762 0 101 0 350 0 5649 0 15070 0 151932 0 0 0 JOYCE HESTER 36574 268214 17640 129359 0 0 1301 9537 397 2912 55912 410022 0 0 BARRY L THIBODEAUX 247724 0 101 0 0 0 7448 0 1940 0 257213 0 0 0 JACK CAPPS 241229 0 101 0 0 0 8130 0 17917 0 267377 0 0 0 PARTICIPATION IN OR PAYMENT FROM SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN SCHEDULE J, PART I, LINE 4B PARTICIPANTS IN SERP REPORTED IN W-2 DEFERRED COMPENSATION -------------------- ---------------- --------------------- RAY THOMPSON $528,232 NONE TAX INDEMNIFICATION & GROSS UP PAYMENTS SCHEDULE J, PART I, LINE 1A Amounts paid for "grossed up" gift cards are included as taxable compensation for the following directors: THOMAS CAMMACK, MATTHEW VIERKANT, MICHAEL LEWIS, KLEANTHE CARUSO, BARRY THIBODEAUX, JACK CAPPS, BEN BETHARD, AND MICHAEL BENTOSKI 1099S REPORTED BY ORGANIZATION FORM 990, PART V, LINE 1A THE ORGANIZATION'S 1099S ARE ISSUED BY A RELATED ORGANIZATION, MOTHER FRANCES HOSPITAL REGIONAL HEALTH CARE CENTER, WHO REPORTS ALL 1099S FOR THE ENTIRE SYSTEM AND ALLOCATES EXPENSES TO THE APPROPRIATE RELATED ORGANIZATION. DESCRIBE THE ORGANIZATION'S MEMBERS OR STOCKHOLDERS FROM 990, PART VI, SECTION A, LINE 6 TRINITY MOTHER FRANCES HEALTH SYSTEM IS THE SOLE MEMBER OF MOTHER FRANCES HOSPITAL - JACKSONVILLE. MEMBERS OR STOCKHOLDERS WHO MAY ELECT MEMBERS OF THE GOVERNING BOARD FORM 990, PART VI, SECTION A, LINE 7A THE SOLE MEMBER, TRINITY MOTHER FRANCES HEALTH SYSTEM, APPOINTS ALL DIRECTORS AND THEIR SUCCESSORS TO THE GOVERNING BOARD. DECISIONS OF GOVERNING BODY SUBJECT TO APPROVAL BY MEMBER FORM 990, PART VI, SECTION A, LINE 7B THE MEMBER HAS THE RIGHT TO APPROVE OR DISAPPROVE CERTAIN ACTIONS THAT HAVE BEEN APPROVED BY THE BOARD OF DIRECTORS. DESCRIBE REVIEW PROCESS OF FORM 990 FORM 990, PART VI, SECTION B, LINE 11B THE ORGANIZATION ENGAGES AN OUTSIDE ACCOUNTING FIRM TO PREPARE FORM 990. ONCE PREPARED, THE FORM IS REVIEWED BY THE ORGANIZATION'S INTERNAL ACCOUNTANTS AND A COPY IS PROVIDED TO THE BOARD PRIOR TO FILING. HOW DOES THE ORGANIZATION MONITOR AND ENFORCE COMPLIANCE WITH POLICY FORM 990, PART VI, SECTION B, LINE 12C THE BOARD REVIEWS AND RESOLVES, IF NECESSARY, ANY TRANSACTIONS AS THEY ARISE THROUGHOUT THE YEAR IN ACCORDANCE WITH POLICY STANDARDS. PROCESS FOR DETERMINING COMPENSATION OF CEO, OFFICERS, OR KEY EMPLOYEES FORM 990, PART VI, SECTION B, LINES 15A & 15B THE ORGANIZATION USES COMPENSATION CONSULTANTS AND NATIONAL COMPENSATION SURVEYS TO DETERMINE COMPENSATION OF EMPLOYEES. COMPENSATION IS APPROVED BY THE ORGANIZATION'S GOVERNING BODY. DESCRIBE WHETHER THE ORGANIZATION MAKES ITS DOCUMENTS AVAILABLE TO PUBLIC FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. COMPENSATION FROM RELATED ORGANIZATIONS FORM 990, PART VII, SECTION A & SCHEDULE J, PART II THE GOVERNING BOARD OF TRINITY MOTHER FRANCES HEALTH SYSTEM, UPON ADVICE FROM NATIONALLY RECOGNIZED COMPENSATION CONSULTANTS, WHO PERIODICALLY REVIEW ALL EXECUTIVE COMPENSATION, APPROVED A DEFERRED COMPENSATION PLAN THAT PROVIDES A 65% TOTAL RETIREMENT BENEFIT FOR SENIOR EXECUTIVES THAT SERVE 20 YEARS OR MORE. THIS PROGRAM HAS BOTH RETENTION AND NON-COMPETITION CLAUSES THAT CREATE A RISK OF FORFEITURE. DEFERRED COMPENSATION IS SUBJECT TO A RISK OF FORFEITURE BASED ON RETENTION, NON-COMPETITION AND OTHER CONTRACTUAL FACTORS. ACCRUALS OF DEFERRED COMPENSATION ARE NOT INCLUDIBLE IN W-2 COMPENSATION UNTIL PAID. OTHER EMPLOYEE BENEFITS INCLUDE QUALIFIED PENSION PLANS, HEALTH, DENTAL, AND LIFE INSURANCE PLANS, DISABILITY INSURANCE, ETC. TAXABLE EXPENSES ARE INCLUDED IN THE W-2 PAID COMPENSATION SALARY AMOUNT. other fees for services form 990, part ix, line 11g Purchased Services $3,798,118 Professional Fees $6,985,172 Contract Labor $282,389 Corporate Expense $1,623,125 Overhead Fees $12,804 ---------------- Total $12,701,608 MOTHER FRANCES HOSP REGIONAL HC CENTER 1315 DOCTORS DRIVE TYLER TX 75701 750818167 HOSPITAL TX 501(C)(3) 3 TMFHS false TRINITY MOTHER FRANCES HEALTH SYSTEM FDN 1315 DOCTORS DRIVE TYLER TX 75701 752028241 SUPPORT TX 501(C)(3) 11, Type I TMFHS false REGIONAL MEDICAL SERVICES ASSOCIATION 1315 DOCTORS DRIVE TYLER TX 75701 752511459 HEALTHCARE TX 501(C)(3) 3 MFH REG false TRINITY MOTHER FRANCES HEALTH SYSTEM 1315 DOCTORS DRIVE TYLER TX 75701 752616975 SUPPORT TX 501(C)(3) 11, Type I NA false TRINITY CLINIC 1315 DOCTORS DRIVE TYLER TX 75701 752616977 HEALTHCARE TX 501(C)(3) 3 TMFHS false MOTHER FRANCES HOSPITAL - WINNSBORO 1315 DOCTORS DRIVE TYLER TX 75701 752771569 HOSPITAL TX 501(C)(3) 3 TMFHS false tri-state financial llc 1315 DOCTORS DRIVE TYLER TX 75701 752728318 COLLECTION AGENCY TX TMFHS C-CORPORATION false TRINCARE INC 1315 DOCTORS DRIVE TYLER TX 75701 752161369 RETAIL HEALTH SVC TX TMFHS C-CORPORATION false HEALTHPLAN OF TEXAS INC 1315 doctors drive TYLER TX 75701 752636832 THIRD PARTY ADMIN TX TMFHS C-CORPORATION false REGIONAL HEALTHCARE ALLIANCE 1315 DOCTORS DRIVE TYLER TX 75701 752484109 PREFER PROVIDER TX TMFHS C-CORPORATION false TEXAS HEALTH FACILITIES INSUR CORP LTD PO BOX 1109 BWI GRAND CAYMAN CJ 980136025 INSURANCE CJ MFH REG C-CORPORATION false CONCORDIUM HEALTH LLC 1315 DOCTORS DRIVE TYLER TX 75701 702811022 INACTIVE TX NA C-CORPORATION false false false false false false false false false false false true false true true true true true false false DIRECT CONTROLLING ENTITY SCHEDULE R, PART II, COLUMN F THE FOLLOWING RELATED ORGANIZATIONS REPORTABLE IN PART II ARE DIRECTLY CONTROLLED BY TRINITY MOTHER FRANCES HEALTH SYSTEM ("TMFHS"): MOTHER FRANCES HOSPITAL REGIONAL HEALTH CARE CENTER TRINITY MOTHER FRANCES HEALTH SYSTEM FOUNDATION TRINITY CLINIC MOTHER FRANCES HOSPITAL - WINNSBORO REGIONAL MEDICAL SERVICES ASSOCIATION IS DIRECTLY CONTROLLED BY MOTHER FRANCES HOSPITAL REGIONAL HEALTH CARE CENTER ("MFH REG").