2014-05-14T09:17:21-05:00 2013-06-30 420714325 MCGLADREY LLP 201 N HARRISON STREET SUITE 300 DAVENPORT IA 528011999 990 2012-07-01 370808925 THE HOPEDALE MEDICAL FOUNDATION HOPE 3094494298 PO BOX 267 HOPEDALE IL 61747 ALFRED N ROSSI MD 3094494298 2014-05-08 1 JOHN J ROMANO P00227323 5638884000 2012 2015-11-30 17:44:51Z HOPEDALE MEDICAL COMPLEX ALFRED N ROSSI MD PO BOX 267 HOPEDALE IL 61747 23997541 0 X WWW.HOPEDALEMC.COM X 1961 IL MAINTAIN A MEDICAL COMPLEX THAT INCLUDES AN ACUTE CARE HOSPITAL AND HEALTH CARE FACILITY. 8 4 434 35 616160 -304838 71741 128049 20842325 18994402 66414 76914 2685490 3081022 23665970 22280387 28493 23013 0 0 12727614 12544896 0 0 19520 9715076 8624525 22471183 21192434 1194787 1087953 22996627 31326718 8151910 15343732 14844717 15982986 X THE HOPEDALE MEDICAL FOUNDATION IS A NON-PROFIT, CHARITABLE CORPORATION COMMITTED TO EXCELLENCE IN PROMOTING GOOD HEALTH AND WELLNESS TO ALL, AND SERVING THE HEALTHCARE NEEDS OF THE SICK AND ELDERLY, 24 HOURS A DAY, 7 DAYS A WEEK, WITHOUT DISCRIMINATION AND REGARDLESS OF ONE'S ABILITY TO PAY. 0 0 15729237 23013 16371165 THE HOPEDALE MEDICAL COMPLEX IS OWNED AND OPERATED BY THE NOT-FOR-PROFIT CHARITABLE CORPORATION KNOWN AS THE HOPEDALE MEDICAL FOUNDATION. THE HOPEDALE MEDICAL COMPLEX STARTED AS A 20-BED HOSPITAL IN 1955 IN HOPEDALE, ILLINOIS AND HAS EXPANDED OVER THE YEARS TO OFFER A CONTINUUM OF CARE SERVICES, INCLUDING A 25-BED ACUTE CARE HOSPITAL, NURSING HOME, INDEPENDENT AND ASSISTED LIVING FACILITY AS WELL AS A WELLNESS CENTER.THE HOPEDALE HOSPITAL IS A CRITICAL ACCESS HOSPITAL AND OFFERS VIRTUALLY THE SAME SERVICES AS A LARGER, URBAN HOSPITAL, INCLUDING 24 HOUR EMERGENCY ROOM, ICU, GENERAL AND ADVANCED VASCULAR SURGERY, ORTHOPEDIC SURGERY, PLASTIC/RECONSTRUCTIVE SURGERY, OPEN MRI AND CT SCANNER. THE HOPEDALE MEDICAL COMPLEX ALSO OFFERS PHYSICIAN SERVICES THROUGH FOUR SATELLITE OFFICES IN ATLANTA, MANITO, MACINAW AND DELAVAN.HOPEDALE WELLNESS CENTER HAS AN INDOOR GYM, WALKING TRACK, THREE THERAPY POOLS, DAY CARE, PHYSICAL THERAPY DEPARTMENT AND CONFERENCE ROOM FOR THEIR MEMBERS TO USE. THE WELLNESS CENTER ALSO OFFERS CLUB MEMBERSHIPS TO THE RESIDENTS OF HOPEDALE AND SURROUNDING AREAS. PRESENTLY, THE WELLNESS CENTER HAS APPROXIMATELY 1,000 MEMBERS WHO ENROLLED IN VARIOUS PROGRAMS AND ACTIVITIES. A SPORTS MEDICINE PROGRAM HAS ALSO BEEN DEVELOPED FOR LOCAL SCHOOL DISTRICTS AND SPORTS TEAMS THAT THE COMPLEX SERVES TO IMPROVE CONDITIONING OF ATHLETES AND TO REDUCE SPORTS INJURIES. THE COST TO OPERATE THE WELLNESS CENTER IS MORE THAN THE REVENUE THAT IS DERIVED FROM THE HEALTH MEMBERSHIPS WITH THE DIFFERENCE REPRESENTING A BENEFIT TO THE RESIDENTS AND THE COMMUNITY.SERVICE AREATHE HOPEDALE MEDICAL COMPLEX SERVES THE MEDICAL NEEDS OF THE LOCAL CITIZENS WITHIN A 50 MILE RADIUS OF HOPEDALE, ILLINOIS. THE HOPEDALE MEDICAL COMPLEX OPERATES FOUR SATELLITE PHYSICIAN OFFICES IN ADDITION TO A PHYSICIAN'S OFFICE LOCATED ON THE MAIN CAMPUS FOR THE CONVENIENCE OF OUR PATIENTS WITHIN OUR SERVICES AREA.HOSPITAL STAFFTHE HOPEDALE MEDICAL COMPLEX HAS A DEDICATED STAFF OF TRAINED HEALTH PROFESSIONALS THAT HAVE JOINED TOGEATHER AS A TEAM TO PROVIDE THE BEST POSSIBLE HEALTH CARE FOR THE PATIENTS AND RESIDENTS OF OUR COMMUNITY.FINANCIAL ASSISTANCE PROGRAMSTHE HOPEDALE MEDICAL COMPLEX HAS POLICIES IN PLACE TO ENSURE THAT NECESSARY HEALTH SERVICES ARE NOT DENIED BASED ON ABILITY TO PAY AND THAT ALL PATIENTS ARE TREATED FAIRLY AND EQUITABLY, AND WITH RESPECT AND COMPASSION. HOPEDALE MEDICAL COMPLEX ASSISTS PERSONS WITHOUT INSURANCE COVERAGE BY WAIVING ALL OR PART OF THE CHARGES FOR SERVICES IT PROVIDES. SIGNS ARE POSTED IN THE ADMITTING AREAS SO THAT HOSPITAL POLICIES ARE CLEARLY COMMUNICATED TO PATIENTS AND PROSPECTIVE PATIENTS.EMERGENCY SERVICESTHE HOPEDALE MEDICAL COMPLEX OPERATES AN EMERGENCY ROOM THAT IS OPEN 24 HOURS A DAY, 365 DAYS A YEAR. THE EMERGENCY ROOM PROVIDES SERVICE TO ALL INDIVIDUALS, REGARDLESS OF THEIR ABILITY TO PAY AND DENIES SERVICE TO NO ONE.COMMUNITY LEADERSHOPEDALE MEDICAL FOUNDATION'S BOARD OF DIRECTORS IS COMPOSED OF VARIOUS LEADERS FROM THE COMMUNITY. THE DIRECTOR'S REPRESENT DIVERSE BACKGROUNDS AND INDUSTRIES WITHIN THE COMMUNITY.MEDICAL STAFFTHE MEDICAL STAFF AT HOPEDALE MEDICAL CENTER IS OPEN AND OFFERS PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN THE AREA.UNCOMPENSATED CARETHE HOPEDALE MEDICAL COMPLEX PARTICIPATES IN MEDICARE, MEDICAID, CHAMPUS, TRICARE AND OTHER GOVERNMENT SPONSORED HEALTH CARE PROGRAMS. THE CONTRACTED AMOUNT FOR THE ABOVE SERVICES EXCEPT MEDICARE IS OFTEN LESS THAN THE ACTUAL COST OF THE SERVICES, WITH THE DIFFERENCE REPRESENTING A BENEFIT TO THE PATIENT AND THE COMMUNITY. 1816134 3207207 HOPEDALE NURSING HOME IS A 52-BED LICENSED FACILITY OFFERING 24-HOUR NURSING CARE. IT IS PHYSICALLY LOCATED ON CAMPUS AND CONNECTED TO THE HOSPITAL FOR THE CONVENIENCE OF OUR RESIDENTS AND THEIR FAMILIES. 847234 1360931 HOPEDALE COMMONS IS A 67-BED INDEPENDENT AND ASSISTED LIVING FACILITY. IT IS ALSO LOCATED ON CAMPUS AND IS LOCATED NEAR THE HOSPITAL FOR THE CONVENIENCE OF OUR RESIDENTS AND THEIR FAMILIES. OTHER COMMUNITY ACTIVITIES -ANNUAL 5K RUN/WALKEACH JULY 4TH, THE HOPEDALE WELLNESS CENTER SPONSORS A 5K RUN/WALK OPEN TO ALL RESIDENTS OF THE COMMUNITY. AWARDS ARE GIVEN TO DIFFERENT WINNERS OF VARIOUS AGE GROUPS OF RUNNERS AND WALKERS.DIETICIAN HEALTHY EATING SEMINARSTHE HOPEDALE MEDICAL FOUNDATION DIETICIAN HOLDS VARIOUS SEMINARS ANNUALLY TO HELP RESIDENTS OF THE COMMUNITY AND EMPLOYEES TO EAT A HEALTHIER DIET. VARIOUS RECIPES ARE GIVEN TO PARTICIPANTS WHICH ENCOURAGE HEALTHIER DIETS. 18392605 1 1 0 1 0 0 0 0 1 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 1 1 1 0 0 0 0 0 1 0 1 1 1 0 0 0 0 1 1 1 1 0 0 1 78 0 1 434 1 1 1 0 0 0 0 0 0 0 0 0 X 8 4 1 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 0 0 IL X DWIGHT JOHNSON 3094494362 107 TREMONT STREET HOPEDALE IL 61747 X ALFRED N ROSSI MD 2.00 X X 62721 0 0 MATTHEW B ROSSI MD 2.00 X X 52418 0 18722 MICHAEL J MCLAUGHLIN 2.00 X 334760 0 0 ROLAND RICH 2.00 X 0 0 0 TOM HIESER 2.00 X 0 0 0 RAY SLACK 2.00 X 0 0 0 JARIE SLACK 2.00 X 0 0 0 DONALD OSWALD 2.00 X 12264 0 0 MARK F ROSSI 40.00 X 208894 0 6630 JOHN ZANON 40.00 X 126200 0 26177 WENDY MOBLEY 40.00 X 114491 0 7897 LAWRENCE KLOC 40.00 X 100563 0 25408 1012311 0 84834 5 1 1 0 EMERGENCY PHYSICIAN STAFFING SOLUTIONS 12528 SR 78 HAVANA IL 62644 STAFFING AGENCY 903838 TRI-COUNTY ANESTHESIA SC PO BOX 267 HOPEDALE IL 61747 ANESTHESIA SERVICES 405400 MICHAEL J MCLAUGHLIN 2 DEEPWOOD ROAD BARRINGTON HILLS IL 60010 CONSULTING SERVICES 334760 PEARL TECHNOLOGY 1200 E GLEN AVE PEORIA HEIGHTS IL 61616 IT SERVICES 293904 FIDELITY ON CALL 9006 N INDUSTRIAL ROAD PEORIA IL 61615 STAFFING AGENCY 190838 5 60733 67316 128049 PATIENT SERVICE REVENUE 621110 14492943 14492943 NURSING HOME 623000 3207207 3207207 ASSISTED AND INDEPENDENT 623000 1360931 1360931 WELLNESS CENTER 713940 367525 367525 MASSAGE THERAPY 621110 74105 74105 -508309 -508309 18994402 71214 71214 294969 0 294969 294969 294969 5700 0 5700 5700 5700 4277990 1717154 2560836 2018781 542055 CHILD CARE 624410 131970 131970 CAFETERIA INCOME 722210 93022 93022 MISCELLANEOUS 900099 225 225 225217 22280387 20939303 616160 596875 8720 8720 14293 14293 842925 545139 297786 309544 209807 99737 9514034 8735109 778925 135179 117193 17986 1065296 1037627 27669 677918 596360 81558 10134 10134 124007 124007 8555 8555 943603 540486 396500 6617 155384 22944 128531 3909 2834691 2652857 175460 6374 829 829 731200 635905 95295 52966 35535 14811 2620 261021 233795 27226 997726 957292 40434 116110 18530 97580 SERVICES 1353122 1030767 322355 MEDICAID TAXES 378794 378794 REPAIRS & MAINTENANCE 328089 284603 43486 DIRECTORSHIP EXPENSE 150000 150000 178294 178294 21192434 18392605 2780309 19520 5676769 8085784 961983 5275218 288289 109016 2598206 2596798 36495 36495 101236 85788 778416 797037 115051 73273 34017235 22905151 10486241 11112084 902449 1848970 1051492 1306255 22996627 31326718 2401222 1912696 388192 373504 3675000 10835208 1687496 2222324 8151910 15343732 X 13593001 14664885 1251716 1318101 14844717 15982986 22996627 31326718 X 1087953 -5178 55494 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 8555 8555 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: PART II-B, LINE 1I, OTHER LOBBYING ACTIVITIES: LOBBYING EXPENDITURES RELATED TO MEMBERSHIP DUES INCLUDED: $8,555 OF MEMBERSHIP DUES TO THE ILLINOIS HOSPITAL ASSOCIATION. 1 2624 0 1383 1241 0 701461 701461 13935444 7698399 6237045 16583042 14666104 1916938 2797288 540648 2256640 11112084 ACCRETION LIABILITY 247841 CAPITALIZED LEASE OBLIGATIONS 127975 ESTIMATED THIRD PARTY PAYOR SETTLEMENT 1770292 INTEREST RATE SWAP AGREEMENT 76216 2222324 X PART IV, LINE 1B: SOME NURSING HOME PATIENTS HOLD SMALL AMOUNTS OF FUNDS ON DEPOSIT WITH THE ORGANIZATION FOR INCIDENTALS AND LOW VALUE SERVICES, SUCH AS HAIR-CUTS. THE ORGANIZATION DOES NOT RECORD THE AMOUNTS AS ASSETS OF THE ORGANIZATION. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: THE HEALTH ASSOCIATION AND ITS TWO NOT-FOR-PROFIT SUBSIDIARIES HAVE BEEN RECOGNIZED AS TAX EXEMPT PURSUANT TO SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND A SIMILAR PROVISION OF STATE LAW. HOWEVER, THE HEALTH ASSOCIATION AND ITS TWO NOT-FOR-PROFIT SUBSIDIARIES ARE SUBJECT TO FEDERAL INCOME TAX ON ANY UNRELATED BUSINESS TAXABLE INCOME. AS PRIVATE FOUNDATIONS, THE HEALTH ASSOCIATION AND ONE OF ITS SUBSIDIARIES, PRAIRIE HEALTH SERVICES, INC, ARE REQUIRED TO DISTRIBUTE A MINIMUM PERCENTAGE OF THE FAIR MARKET VALUE OF THEIR INVESTMENT ASSETS ANNUALLY. HRES IS A FOR-PROFIT CORPORATION SUBJECT TO APPLICABLE FEDERAL AND ILLINOIS TAXES ON INCOME. HRES COMPUTES DEFERRED INCOME TAXES UNDER THE LIABILITY METHOD WHEREBY DEFERRED TAX ASSETS ARE RECOGNIZED FOR DEDUCTIBLE TEMPORARY DIFFERENCES AND NET OPERATING LOSS AND TAX CREDIT CARRYFORWARDS AND DEFERRED TAX LIABILITIES ARE RECOGNIZED FOR TAXABLE TEMPORARY DIFFERENCES. TEMPORARY DIFFERENCES ARE THE DIFFERENCES BETWEEN THE REPORTED AMOUNTS OF ASSETS AND LIABILITIES AND THEIR TAX BASES. DEFERRED TAX ASSETS ARE REDUCED BY A VALUATION ALLOWANCE WHEN, IN THE OPINION OF MANAGEMENT, IT IS MORE LIKELY THAN NOT THAT SOME OR ALL OF THE DEFERRED TAX ASSETS WILL NOT BE REALIZED. DEFERRED TAX ASSETS AND LIABILITIES ARE ADJUSTED FOR THE EFFECTS OF CHANGES IN TAX LAWS AND RATES ON THE DATE OF ENACTMENT. THE TAXABLE INCOME OF HRES AND ITS RELATED CURRENT AND DEFERRED INCOME TAXES ARE NOT SIGNIFICANT TO THE CONSOLIDATED FINANCIAL STATEMENTS AND ARE NOT, THEREFORE, SEPARATELY PRESENTED. THE HEALTH ASSOCIATION AND PRAIRIE HEALTH SERVICES, INC, FILE FORM 990-PF (RETURN OF PRIVATE FOUNDATION) ANNUALLY. HOPEDALE MEDICAL FOUNDATION FILES A FORM 990 (RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX) ANNUALLY. WHEN THESE RETURNS ARE FILED, IT IS HIGHLY CERTAIN THAT SOME POSITIONS TAKEN WOULD BE SUSTAINED UPON EXAMINATION BY THE TAXING AUTHORITIES, WHILE OTHERS ARE SUBJECT TO UNCERTAINTY ABOUT THE MERITS OF THE TAX POSITION TAKEN OR THE AMOUNT OF THE POSITION THAT WOULD ULTIMATELY BE SUSTAINED. EXAMPLES OF TAX POSITIONS COMMON TO HOSPITALS INCLUDE SUCH MATTERS AS THE FOLLOWING: THE TAX EXEMPT STATUS OF THE ENTITY AND VARIOUS POSITIONS RELATIVE TO POTENTIAL SOURCES OF UNRELATED BUSINESS INCOME (UBI). AN EXCISE TAX OF 2% IS IMPOSED ON NET INVESTMENT INCOME OF ALL DOMESTIC TAX-EXEMPT PRIVATE FOUNDATIONS FOR EACH TAX YEAR, AND IS REPORTED ON FORM 990-PF. UBI IS REPORTED ON FORM 990T, AS APPROPRIATE. THE BENEFIT OF A TAX POSITION IS RECOGNIZED IN THE FINANCIAL STATEMENTS IN THE PERIOD DURING WHICH, BASED ON ALL AVAILABLE EVIDENCE, MANAGEMENT BELIEVES THAT IT IS MORE LIKELY THAN NOT THAT THE POSITION WILL BE SUSTAINED UPON EXAMINATION, INCLUDING THE RESOLUTION OF APPEALS OR LITIGATION PROCESSES, IF ANY. TAX POSITIONS ARE NOT OFFSET OR AGGREGATED WITH OTHER POSITIONS. TAX POSITIONS THAT MEET THE "MORE LIKELY THAN NOT" RECOGNITION THRESHOLD ARE MEASURED AS THE LARGEST AMOUNT OF TAX BENEFIT THAT IS MORE THAN 50% LIKELY TO BE REALIZED ON SETTLEMENT WITH THE APPLICABLE TAXING AUTHORITY. THE DIFFERENCE BETWEEN THE BENEFIT OF A TAX POSITION RECORDED FOR FINANCIAL STATEMENT PURPOSES AND THE AMOUNT REFLECTED ON A TAX RETURN IS RECORDED AS A LIABILITY FOR UNCERTAIN TAX BENEFITS IN THE ACCOMPANYING BALANCE SHEETS ALONG WITH ANY ASSOCIATED INTEREST AND PENALTIES THAT WOULD BE PAYABLE TO THE TAXING AUTHORITIES UPON EXAMINATION. AS OF JUNE 30, 2013 AND 2012, THERE WERE NO UNCERTAIN TAX BENEFITS RELATED TO UNCERTAIN TAX POSITIONS IDENTIFIED AND RECORDED AS A LIABILITY. FORMS 990-PF, 990, 990-T, AND 1120 FILED BY THE HEALTH ASSOCIATION AND ITS SUBSIDIARIES ARE SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE (IRS) UP TO THREE YEARS FROM THE EXTENDED DUE DATE OF EACH RETURN. GENERALLY, FORMS 990-PF, 990, 990-T, AND 1120 FILED BY THE HEALTH ASSOCIATION AND ITS SUBSIDIARIES ARE NO LONGER SUBJECT TO EXAMINATION FOR THE YEARS ENDED JUNE 30, 2009 AND PRIOR. 1 1 1 X 300.000000000000 1 X 1 1 1 0 0 764357 0 764357 0.03610 866118 617597 248521 0.01170 150012 0 150012 0.00710 1780487 617597 1162890 0.05490 669685 501753 167932 0.00790 1691 0 1691 0.00010 0 0 0 0 0 0 671376 501753 169623 0.00800 2451863 1119350 1332513 0.06290 1 508309 267000 6268689 6227653 41036 X 1 1 1 1 HOPEDALE MEDICAL FOUNDATION

107 TREMONT STREET HOPEDALE IL 61747

WWW.HOPEDALEMC.COM X X X X HOPEDALE MEDICAL COMPLEX 1 1 X X X X X X X X X 11 1 0 1 X X X X X X X X 1 0 1 1 300.000000000000 1 300.000000000000 1 X X X X X X X 1 1 X X X X X 1 0 X X X X 1 X 0 0 8 HOPEDALE NURSING HOME

111 TREMONT STREET HOPEDALE IL 61747

NURSING HOME HOPEDALE COMMONS

211 221 SW RAILROAD STREET HOPEDALE IL 61747

ASSISTED AND INDEPENDENT LIVING HOPEDLAE WELLNESS CENTER

107 TREMONT STREET HOPEDALE IL 61747

WELLNESS & FITNESS CENTER MEDICAL ARTS PHYSICIAN BUILDING

107 TREMONT STREET HOPEDALE IL 61747

OUTPATIENT PHYSICIAN CLINIC DELAVAN DOCTOR'S OFFICE

115 EAST 4TH STREET DELAVAN IL 61734

OUTPATIENT PHYSICIAN CLINIC ATLANTA DOCTOR'S OFFICE

108 SW ARCH STREET ATLANTA IL 61723

OUTPATIENT PHYSICIAN CLINIC MACKINAW DOCTOR'S OFFICE

407 S ORCHARD STREET MACKINAW IL 61755

OUTPATIENT PHYSICIAN CLINIC MANITO DOCTOR'S OFFICE

101 E MASON MANITO IL 61546

OUTPATIENT PHYSICIAN CLINIC PART I, LINE 3C: NOT APPLICABLE PART I, LINE 6A: NOT APPLICABLE PART I, LINE 7: THE ORGANIZATION CALCULATED THE COST AMOUNTS NOTED IN PART I, LINE 7 BY UTILIZING ITS CURRENT COST ACCOUNTING SYSTEM. THE COST ACCOUNTING SYSTEM ADDRESSES ALL PATIENT SEGMENTS REPORTED ON, INCLUDING, BUT NOT LIMITED TO INPATIENT, OUTPATIENT, MEDICAID, UNINSURED, AND MEDICARE. PART I, LINE 7G: NOT APPLICABLE PART I, L7 COL(F): NO BAD DEBT EXPENSE WAS INCLUDED IN THE DENOMINATOR BECAUSE BAD DEBT WAS REPORTED IN LINE 2F OF PART VIII, STATEMENT OF REVENUE. THE ORGANIZATION'S TOTAL COMMUNITY BENEFIT EXPENSE AS A PERCENTAGE OF TOTAL EXPENSES IS 11.57%, AND THE PERCENTAGE INCREASES TO 40.96% IF MEDICARE ALLOWABLE COSTS ARE INCLUDED IN TOTAL COMMUNTY BENEFIT EXPENSE. PART II: NOT APPLICABLE PART III, LINE 2: BAD DEBT IS REPORTED AT THE FULL-ESTABLISHED CHARGE FROM THE MOST RECENT AUDITED FINANCIAL REPORT. ANY RECOVERIES ARE RECORDED AS A REDUCTION OF BAD DEBT EXPENSE WHEN RECEIVED. PART III, LINE 3: THE ORGANIZATION USED A COST TO CHARGE RATIO TO DETERMINE THE COST AMOUNT OF THE BAD DEBT EXPENSE. WORKSHEET 2, RATIO OF PATIENT CARE COST TO CHARGES, AS PROVIDED IN THE IRS INSTRUCTIONS WAS USED TO DETERMINE THE APPROPRIATE RATIO. PART III, LINE 4: THE TEXT FROM THE FOOTNOTE TO HOPEDALE RURAL HEALTH ASSOCIATION, INC.'S FINANCIAL STATEMENT IS AS FOLLOWS: PATIENT RECEIVABLES DUE DIRECTLY FROM THE PATIENTS ARE CARRIED AT THE ORIGINAL CHARGE FOR THE SERVICE PROVIDED LESS AMOUNTS COVERED BY THIRD-PARTY PAYORS AND LESS AN ESTIMATED ALLOWANCE FOR DOUBTFUL RECEIVABLES BASED ON A REVIEW OF ALL OUTSTANDING ACCOUNTS ON A MONTHLY BASIS. MANAGEMENT DETERMINES THE ALLOWANCE FOR DOUBTFUL ACCOUNTS BY IDENTIFYING TROUBLED ACOUNTS AND BY HISTORICAL EXPERIENCE APPLIED TO AN AGING OF ACCOUNTS. THE ORGANIZATION DOES NOT CHARGE INTEREST ON PATIENT RECEIVABLES. PATIENT ACCOUNTS RECEIVABLE ARE DUE IN FULL WHEN BILLED. ACCOUNTS ARE CONSIDERED PAST DUE WHEN AN AMOUNT IS PAST DUE ACCORDING TO THE PAYORS' AGREED-UPON TERMS. PATIENT RECEIVABLES ARE WRITTEN OFF AS BAD DEBT EXPENSE WHEN DEEMED UNCOLLECTIBLE. RECOVERIES OF RECEIVABLES PREVIOUSLY WRITTEN OFF ARE RECORDED AS A REDUCTION OF BAD DEBT EXPENSE WHEN RECEIVED. AS A SERVICE TO THE PATIENT, THE ORGANIZATION BILLS THIRD-PARTY PAYORS DIRECTLY AND THE PATIENT WHEN THE PATIENT'S LIABILITY IS DETERMINED. PART III, LINE 8: THE ORGANIZATION DERIVED ITS COSTING METHODOLOGY USED TO DETERMINE THE MEDICARE ALLOWABLE COSTS REPORTED IN THE ORGANIZATION'S MEDICARE COST REPORT BY USING COST REPORT WORKSHEETS. MEDICARE COSTS ARE DETERMINED THROUGH THE MEDICARE COST FINDING PROCESS WHICH ALLOCATES GENERAL SERVICE CENTER COSTS TO REVENUE DEPARTMENTS. ROUTINE AND ICU COSTS ARE DETERMINED BASED ON AN AVERAGE COST PER DAY MULTIPLIED BY THE NUMBER OF MEDICARE ALLOWABLE DAYS. MEDICARE ANCILLARY COSTS ARE DETERMINED BY THE RATIO OF DEPARTMENT COSTS TO DEPARTMENT CHARGES THEN THE RESULTING % IS APPLIED TO MEDICARE ALLOWABLE CHARGES. THE METHODOLOGY DESCRIBED IN THE INSTRUCTIONS TO SCHEDULE H, PART III, SECTION B, LINE 6 DOES NOT TAKE INTO ACCOUNT ALL COSTS INCURRED BY THE HOSPITAL AND DOES NOT REPRESENT THE TOTAL COMMUNITY BENEFIT CONFERRED IN THIS AREA. PART III, LINE 9B: THE ORGANIZATION APPLIES THE FOLLOWING PROCESSES AND PROCEDURES IN ITS COLLECTION PRACTICES FOR THOSE WHO MAY QUALIFY FOR FINANCIAL ASSISTANCE POLICY:THE DISTINCTION BETWEEN CHARITY CARE AND BAD DEBT IS THE INABILITY TO PAY VERSUS THE UNWILLINGNESS OF THE PERSON TO PAY THEIR ACCOUNT. THOSE WITH LOW INCOMES OR WITH CATASTROPHIC MEDICAL BILLS MAY BE MEDICALLY INDIGENT EVEN THOUGH THEY ARE ABLE TO MEET BASIC LIVING EXPENSES. HOPEDALE MEDICAL COMPLEX WILL NOT DENY SERVICES TO ANY PATIENT DUE TO RACE, COLOR, RELIGION, GENDER, ANCESTRY, SEXUAL ORIENTATION, FINANCIAL CLASS OR NATIONAL ORIGIN.HOPEDALE MEDICAL FOUNDATION IS COMMITTED, TO THE EXTENT RESOURCES ALLOW, TO PROVIDING QUALITY HEALTHCARE TO ITS PATIENTS AND RESIDENTS REGARDLESS OF THEIR ABILITY TO PAY.THE HOPEDALE MEDICAL FOUNDATION FINANCIAL ASSISTANCE PROGRAM ALLOWS FOR FREE OR REDUCED MEDICAL SERVICES TO PATIENTS WHO RECEIVE INPATIENT AND OUTPATIENT CARE; HAVE NO HEALTH COVERAGE OR HAVE COVERAGE THAT PAYS ONLY FOR PART OF THE BILL AND ARE INELIGIBLE FOR ANY PRIVATE OR GOVERNMENTAL SPONSORED COVERAGE (SUCH AS MEDICAID); AND MEET THE INCOME AND ASSETS ELIGIBILITY CRITERIA.FINANCIAL ASSISTANCE IS AVAILABLE FOR NECESSARY HOSPITAL AND PHYSICIAN CHARGES ONLY.ELIGIBILITY DETERMINATION:FINANCIAL ASSISTANCE FORMS AND INSTRUCTIONS SHALL BE FURNISHED TO PATIENTS WHEN FINANCIAL ASSISTANCE IS REQUESTED, WHEN NEED IS INDICATED, OR WHEN FINANCIAL SCREENING INDICATES POTENTIAL NEED, IN THE CASE OF PATIENTS WITHOUT HEALTH INSURANCE. ALL APPLICATIONS SHOULD BE FOLLOWED BY DOCUMENTATION TO VERIFY INCOME AMOUNTS INDICATED ON THE APPLICATION FORM. ALL INFORMATION RECEIVED RELATING TO THE APPLICATION WILL BE KEPT CONFIDENTIAL AND USED TO VERIFY FINANCIAL NEEDS. STEPS USED BY HOPEDALE MEDICAL FOUNDATION TO DETERMINE AND VERIFY FINANCIAL ASSISTANCE:1) HOSPITAL IDENTIFIES ANY UNINSURED, UNDERINSURED, OR SELF-PAY PATIENTS.2) PATIENT COMPLETES APPLICATION/FINANCIAL STATEMENT THAT INCLUDES INCOME, ASSETS, AND LIABILITIES.3) FINANCIAL COUNSELOR INTERVIEWS PATIENT TO ASSESS THE PATIENT'S ABILITY TO PAY IN FULL; ABILITY TO PAY REASONABLE MONTHLY INSTALLMENTS; AND QUALIFICATION FOR FINANCIAL ASSISTANCE.4) HOSPITAL MAKES INITIAL DETREMINATION BASED UPON APPLICATION AND ANY ORAL INFORMATION PROVIDED BY PATIENT. PATIENT SIGNS APPLICATION CONFIRMING ACCURACY OF INFORMATION PROVIDED.5) PATIENT SUPPLIES DOCUMENTATION OF RESOURCES AND OUTSTANDING OBLIGATIONS WITHIN 30 DAYS FROM DATE OF APPLICATION.6) HOSPITAL MAKES FINAL DETERMINATION REGARDING ELIGIBILITY FOR FINANCIAL ASSISTANCE.7) HOSPITAL SENDS NOTIFICATION LETTER TO THE PATIENT AND/OR FAMILY WITH THE DECISION. NOTICE WILL INCLUDE INSTRUCTIONS FOR ESTABLISHING A PAYMENT PLAN, IF NEEDED, AND REASON FOR DENIAL, IF APPLICABLE. PART V, SECTION B, LINE 5A: WWW.HOPEDALEMC.COM HOPEDALE MEDICAL COMPLEX PART V, SECTION B, LINE 3: HOPEDALE MEDICAL FOUNDATION CREATED THE FOLLOWING FOCUS GROUPS TO GATHER INPUT FOR THE COMMUNITY HEALTH NEEDS ASSESSMENT:1) A FOCUS GROUP MADE UP OF HEALTH PROFESSIONALS AND PARTNERS MET ON NOVEMBER 29, 2011. THE GROUP INCLUDED A DOCTOR, A HOSPICE SERVICE PROVIDER, A REPRESENTATIVE OF THE LOCAL HEALTH DEPARTMENT, AND A REPRESENTATIVE OF AN AMBULANCE SERVICE.2) A FOCUS GROUP MADE UP OF COMMUNITY LEADERS AND ELECTED OFFICIALS MET ON NOVEMBER 29, 2011. THE GROUP INCLUDED REPRESENTATIVES OF LOCAL FINANCIAL INSTITUTIONS, LEGAL SERVICES, A COMMUNITY IMPROVEMENT GROUP AND INDIVIDUAL COMMUNITY LEADERS.3) A FOCUS GROUP MADE UP OF COMMUNITY LEADERS AND ELECTED OFFICIALS MET ON NOVEMBER 30, 2011. THE GROUP INCLUDED THE COUNTY BOARD CHAIRMAN, SCHOOL OFFICIALS, RELIGIOUS LEADERS, A MAYOR, POLICE CHIEFS, AND TOWNSHIP SUPERVISORS. PART VI, LINE 2: SERVICES OFFERED BY THE FOUNDATION INCLUDE MEDICAL/SURGICAL, SWING BED, CRITICAL CARE, OUTPATIENT SURGICAL SERVICES AND A SIGNIFICANT NUMBER OF OTHER ANCILLARY SERVICES NECESSARY TO MEET THE HEALTH CARE NEEDS OF THE COMMUNITY. THE HOSPITAL ALSO OFFERS 24-HOUR EMERGENCY ROOM SERVICES, LABORATORY AND DIAGNOSTIC IMAGING, PHYSICAL THERAPY AND OUTPATIENT/AMBULATORY PROCEDURES. ALTHOUGH CARE IS RENDERED TO ALL TO THE EXTENT POSSIBLE, MIDDLE AGED TO GERIATRIC PATIENT CARE COMPOSES BOTH THE PRIMARY AND SECONDARY SERVICE AREAS AND OUR PATIENT DEMOGRAPHICS. PART VI, LINE 3: SIGNS AND BROCHURES ARE LOCATED IN THE REGISTRATION AND MOST OTHER ENTRANCE AREAS. STAFF IN THE ADMISSIONS AND PATIENT REGISTRATION AREA ARE TRAINED TO RECOMMEND THAT PATIENTS MEET OUR PATIENT FINANCIAL COUNSELOR FOR AN APPLICATION AND TO DISCUSS BILLING AND COLLECTION PROCEDURES. PART VI, LINE 4: SIXTY-FIVE PERCENT OF ADMISSIONS COME FROM 9 CENSUS TRACTS SURROUNDING THE HOSPITAL, THE PRIMARY SERVICE AREA. AN ADDITIONAL EIGHTEEN PERCENT COME FROM 8 CENSUS TRACTS, THE SECONDARY SERVICE AREA, FURTHER, BUT CONTIGUOUS TO THE PRIMARY SERVICE AREA. THE TOTAL SERVICE AREA POPULATION IS 134,000. THE AGES 45-65 COMPOSE 26.5% AND AGE 65+ COMPOSES 15.5% OF THE AREA POPULATION. PART VI, LINE 5: THE FOUNDATION MAINTAINS A WELLNESS CENTER WHICH HAS THERAPY AND EXERCISE POOLS, WEIGHT ROOM AND GYMNASIUM AREAS, A LAP TRACK, EXERCISE MACHINES AND MEETING ROOMS. WEIGHT-LOSS, NUTRITION COUNSELING, AND CHRONIC CONDITION MANAGEMENT SESSIONS ARE HELD IN THE MEETING ROOMS, AS WELL AS COMMUNITY ORGANIZATION MEETINGS. BLOOD DRIVES ARE REGULARLY SCHEDULED. PART VI, LINE 6: NOT APPLICABLE REPORTS FILED WITH STATES PART VI, LINE 7 IL 1 SCHOLARSHIPS FOR STUDENTS ENTERING FIELDS OF HEALTHCARE & AG 29 14293 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: IN KEEPING WITH THE SUPPORT OF EDUCATION OF THE YOUTH IN THE AREA COMMUNITIES, AND ENCOURAGING THEM TO ENTER THE IMPORTANT FIELDS OF HEALTHCARE AND AGRICULTURE, HOPEDALE MEDICAL FOUNDATION AWARDS SCHOLARSHIPS TO HIGH SCHOOL STUDENTS AND COLLEGE FRESHMAN. HOPEDALE MEDICAL FOUNDATION REQUIRES AN APPLICATION FROM STUDENTS FROM QUALIFYING SCHOOLS IN THE LOCAL AREA. SCHOLARSHIPS ARE AWARDED BY AN INDEPENDENT JUDGE BASED ON RECOMMENDATIONS, ACT SCORES, STUDENT NARRATIVE, AND CLASS RANKING. SCHOLARSHIP MONEY IS SENT DIRECTLY TO THE RECIPIENT'S SCHOOL TO ENSURE THE MONEY IS USED TOWARDS TUITION. X X X 0 0 0 0 0 0 0 0 0 MICHAEL J MCLAUGHLIN 0 0 0 0 334760 0 0 0 0 0 334760 0 0 0 MARK F ROSSI 208894 0 0 0 0 0 450 0 6180 0 215524 0 0 0 JOHN ZANON 126200 0 0 0 0 0 3786 0 22391 0 152377 0 0 0 LAWRENCE KLOC 100563 0 0 0 0 0 3017 0 22391 0 125971 0 0 0 A VILLAGE OF HOPEDALE 376002155 2012-10-16 10000000 CAPITAL IMPROVEMENTS - REFUNDING REVENUE BONDS 0 0 0 B VILLAGE OF HOPEDALE 376002155 2012-10-31 1000000 CAPITAL IMPROVEMENT REVENUE BONDS 0 0 0 C VILLAGE OF HOPEDALE 376002155 2012-10-31 2900000 CAPITAL IMPROVEMENT REVENUE BONDS 0 0 0 A 210630 10000000 199143 329540 4201692 5269626 2014 1 0 1 1 B 21063 1000000 63812 110876 825312 2014 0 0 1 1 C 2900000 2900000 2014 0 0 1 1 A 0 0 0 0 0 0 1 B 0 0 0 0 0 0 1 C 0 0 0 0 0 0 1 A 0 1 0 0 1 1 HEARTLAND BANK 20.000000000000 0 0 0 0 1 B 0 1 0 0 1 1 HEARTLAND BANK 20.000000000000 0 0 0 0 1 C 0 1 0 0 1 0 0 0 1 A 1 B 1 C 1 MATTHEW B ROSSI MD SEE BELOW IN PART V PHYSICIAN RENT RECEIVABLE X 36495 36495 0 1 1 AARON ROSSI SEE BELOW IN PART V LOAN TO SUPPORT COMPLETION OF MEDICAL SCHOOL X 50000 50000 0 1 1 PHILLIP ROSSI MD SEE BELOW IN PART V PHYSICIAN RENT RECEIVABLE X 35788 35788 0 1 1 122283 PHILLIP ROSSI MD SEE BELOW IN PART V 74448 PHILLIP ROSSI, M.D. RECEIVES COMPENSATION FROM THE HOPEDALE MEDICAL FOUNDATION FOR HIS SERVICES IN THE EMERGENCY ROOM. 0 TRI-COUNTY ANESTHESIA SC SEE BELOW IN PART V 405400 TRI-COUNTY ANESTHESIA PROVIDES ANESTHESIA SERVICES TO HOPEDALE MEDICAL FOUNDATION. 0 LISA MCLAUGHLIN SEE BELOW IN PART V 43700 LISA MCLAUGHLIN RECEIVES COMPENSATION FROM THE HOPEDALE MEDICAL FOUNDATION AS A PHARMACY DIRECTOR. 0 CYNTHIA NOREUIL SEE BELOW IN PART V 56355 CYNTHIA NOREUIL RECEIVES COMPENSATION FROM THE HOPEDALE MEDICAL FOUNDATION AS THE DIRECTOR OF ASSISTED AND INDEPENDENT LIVING. 0 LARRY NOREUIL SEE BELOW IN PART V 53480 LARRY NOREUIL RECEIVES COMPENSATION AS AN EMPLOYEE OF THE HOPEDALE MEDICAL FOUNDATION. 0 PEGGIE ROSSI SEE BELOW IN PART V 41511 PEGGIE ROSSI RECEIVES COMPENSATION AS AN EMPLOYEE OF THE HOPEDALE MEDICAL FOUNDATION. 0 LORAYNE ROSSI SEE BELOW IN PART V 25080 LORAYNE ROSSI RECEIVES MAINTENANCE PAYMENTS FROM THE HOPEDALE MEDICAL FOUNDATION. 0 PHILLIP NOREUIL SEE BELOW IN PART V 35626 PHILLIP NOREUIL RECEIVES COMPENSATION AS AN EMPLOYEE OF THE HOPEDALE MEDICAL FOUNDATION. 0 MICHAEL J MCLAUGHLIN SEE BELOW IN PART V 334760 MICHAEL MCLAUGHLIN RECEIVES COMPENSATION AS AN INDEPENDENT CONTRACTOR FOR CONSULTING SERVICES PROVIDED TO THE HOPEDALE MEDICAL FOUNDATION. 0 FORM 990, SCHEDULE L, PART II RELATIONSHIP WITH ORGANIZATION: MATTHEW B. ROSSI, M.D. IS THE SECRETARY AND TREASURER OF THE HOPEDALE MEDICAL FOUNDATION BOARD OF DIRECTORS.AARON ROSSI IS THE SON OF LARRY ROSSI, M.D. LARRY ROSSI, M.D. IS THE BROTHER TO MARK, ALFRED, AND MATTHEW ROSSI, ALL OFFICERS OF THE HOPEDALE MEDICAL FOUNDATION BOARD OF DIRECTORS. LARRY ROSSI, M.D. IS ALSO THE OWNER OF TRI-COUNTY ANESTHESIA, S.C., AN ORGANIZATION THAT PROVIDES SERVICES TO THE HOPEDALE MEDICAL FOUNDATION AND IS REPORTED IN PART VII, SECTION B AND SCHEDULE L, PART VI.PHILLIP ROSSI, M.D. IS THE BROTHER TO MARK, ALFRED, AND MATTHEW ROSSI, ALL OFFICERS OF THE HOPEDALE MEDICAL FOUNDATION BOARD OF DIRECTORS. FORM 990, SCHEDULE L, PART IV, COLUMN B: DESCRIPTION OF RELATIONSHIP - PHILLIP ROSSI, M.D. PHILLIP ROSSI, M.D. IS THE BROTHER TO MARK, ALFRED, AND MATTHEW ROSSI, ALL OFFICERS OF THE HOPEDALE MEDICAL FOUNDATION BOARD OF DIRECTORS. FORM 990, SCHEDULE L, PART IV, COLUMN B: DESCRIPTION OF RELATIONSHIP - TRI-COUNTY ANESTHESIA, S.C. LARRY ROSSI, M.D. IS THE BROTHER TO MARK, ALFRED, AND MATTHEW ROSSI, ALL OFFICERS OF THE HOPEDALE MEDICAL FOUNDATION BOARD OF DIRECTORS. LARRY ROSSI, M.D. IS THE OWNER OF TRI-COUNTY ANESTHESIA, S.C. FORM 990, SCHEDULE L, PART IV, COLUMN B: DESCRIPTION OF RELATIONSHIP - LISA MCLAUGHLIN LISA MCLAUGHLIN IS THE SISTER TO MARK, ALFRED, AND MATTHEW ROSSI, ALL OFFICERS OF THE HOPEDALE MEDICAL FOUNDATION BOARD OF DIRECTORS. LISA MCLAUGHLIN'S HUSBAND, MICHAEL J. MCLAUGHLIN, IS ALSO A MEMBER OF THE BOARD OF DIRECTORS. FORM 990, SCHEDULE L, PART IV, COLUMN B: DESCRIPTION OF RELATIONSHIP - CYNTHIA, LARRY, AND PHILLIP NOREUIL CYNTHIA NOREUIL IS THE SISTER TO MARK, ALFRED, AND MATTHEW ROSSI, ALL OFFICERS OF THE HOPEDALE MEDICAL FOUNDATION BOARD OF DIRECTORS. LARRY NOREUILL IS CYNTHIA NOREUIL'S HUSBAND, AND PHILLIP NOREUIL IS HER SON. FORM 990, SCHEDULE L, PART IV, COLUMN B: DESCRIPTION OF RELATIONSHIP - PEGGIE ROSSI PEGGY ROSSI IS THE WIFE OF ALFRED N. ROSSI, M.D., OFFICER OF THE HOPEDALE MEDICAL FOUNDATION BOARD OF DIRECTORS. FORM 990, SCHEDULE L, PART IV, COLUMN B: DESCRIPTION OF RELATIONSHIP - LORAYNE ROSSI LORAYNE ROSSI IS THE MOTHER TO MARK, ALFRED, AND MATTHEW ROSSI, ALL OFFICERS OF THE HOPEDALE MEDICAL FOUNDATION BOARD OF DIRECTORS. FORM 990, SCHEDULE L, PART IV, COLUMN B: DESCRIPTION OF RELATIONSHIP - MICHAEL J. MCLAUGHLIN MICHAEL J. MCLAUGHLIN IS THE BROTHER-IN-LAW TO MARK, ALFRED, AND MATTHEW ROSSI, ALL OFFICERS OF THE HOPEDALE MEDICAL FOUNDATION BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 2 ALFRED ROSSI, DIRECTOR, MATTHEW ROSSI, DIRECTOR, MIKE MCLAUGHLIN, DIRECTOR, AND MARK F. ROSSI, COO ALL HAVE A FAMILY RELATIONSHIP. SEE FURTHER DESCRIPTION REGARDING FAMILY RELATIONSHIPS ON SCH L, PART V. RAY SLACK AND JARIE SLACK HAVE A FAMILY RELATIONSHIP. FORM 990, PART VI, SECTION A, LINE 6 THE SOLE MEMBER OF HOPEDALE MEDICAL FOUNDATION IS HOPEDALE RURAL HEALTH ASSOCIATION, INC., AN ILLINOIS NOT FOR PROFIT ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 7A DIRECTORS SHALL BE APPOINTED TO THE BOARD BY THE BOARD OF DIRECTORS OF THE SOLE MEMBER FROM AMONG THOSE PERSONS NOMINATED BY THE NOMINATING COMMITTEE OF THE SOLE MEMBER. FORM 990, PART VI, SECTION A, LINE 7B THE SOLE MEMBER OF HOPEDALE MEDICAL FOUNDATION, HOPEDALE RURAL HEALTH ASSOCIATION, INC., HAS THE FOLLOWING RIGHTS AND POWERS: A. TO ELECT OR REMOVE, WITH OR WITHOUT CAUSE, MEMBERS OF THE BOARD OF DIRECTORS OF THE FOUNDATION; B. TO ELECT OR REMOVE, WITH OR WITHOUT CAUSE, THE CHAIR, VICE CHAIR, PRESIDENT AND OTHER OFFICERS OF THE FOUNDATION; C. TO ELECT OR REMOVE, WITH OR WITHOUT CAUSE, THE AUDITORS OF THE FOUNDATION; D. TO APPROVE ANY CHANGES TO THE GOVERNANCE DOCUMENTS OF THE FOUNDATION; E. TO APPROVE THE MERGER, CONSOLIDATION, CHANGE IN CORPORATE MEMBERSHIP, CORPORATE REORGANIZATION OR DISSOLUTION OF THE FOUNDATION; F. TO APPROVE THE CREATION OF NEW SUBSIDIARIES OR AFFILIATES BY THE FOUNDATION; G. TO APPROVE THE STRATEGIC AND FINANCIAL PLANS AND THE CAPITAL AND OPERATING BUDGETS OF THE FOUNDATION; H. TO APPROVE DEBT INCURRED BY THE FOUNDATION IN EXCESS OF $500,000; I. TO APPROVE THE PURCHASE, SALE, LEASE, TRANSFER, ENCUMBRANCE OR OTHER DISPOSITION OF ASSETS IN EXCESS OF $150,000; J. TO APPROVE ALL NON-BUDGETED DEBT OR TRANSFERS OF ASSETS IN EXCESS OF AN AMOUNT ESTABLISHED FROM TIME TO TIME BY THE SOLE MEMBER; K. TO APPROVE THE MANAGED CARE POLICY OF THE FOUNDATION; AND L. TO APPROVE THE FILING OF THE BANKRUPTCY BY THE FOUNDATION. FORM 990, PART VI, SECTION B, LINE 11 THE ORGANIZATION'S CONTROLLER REVIEWS THE FORM 990 WITH EXTERNAL ACCOUNTANTS. THE BOARD IS THEN PROVIDED A FINAL COPY OF THE FORM 990 BEFORE IT IS FILED. FORM 990, PART VI, SECTION B, LINE 12C THE CONFLICT OF INTEREST POLICY APPLIES TO ALL MEMBERS OF THE BOARD OF DIRECTORS AND ALL CORPORATE OFFICERS, AGENTS AND EMPLOYEES OF THE FOUNDATION, INCLUDING INDEPENDENT CONTRACTORS, PROVIDERS OF SERVICES AND MATERIALS. AN ANNUAL DISCLOSURE STATEMENT IS COMPLETED BY ALL PERSONS TO WHOM THE CONFLICT OF INTEREST POLICY APPLIES TO ASSIST THEM IN CONSIDERING ALL REAL AND APPARENT CONFLICTS OR DUALITIES IN CONNECTION WITH THE FOUNDATION'S ACTIVITIES. DISCLOSURE IS ALSO REQUIRED WHENEVER CONFLICTS ARISE. THE WRITTEN DISCLOSURE NOTICES OF CONFLICTS ARE FILED WITH THE PRESIDENT OF THE FOUNDATION OR ANY OTHER PERSON DESIGNATED BY THE PRESIDENT. ALL DISCLOSURE NOTICES ARE NOTED FOR RECORD IN THE MINUTES OF A MEETING OF THE BOARD OF DIRECTORS. WHEN OFFICERS, DIRECTORS, EMPLOYEES OR AGENTS BELIEVE THEY HAVE A REAL OR APPARENT CONFLICT, THEY ABSTAIN FROM MAKING MOTIONS, VOTING, EXECUTING AGREEMENT OR TAKING ANY OTHER SIMILAR DIRECT ACTION ON BEHALF OF THE FOUNDATION. THEY ARE NOT PRECLUDED FROM DEBATE OR OTHER SIMILAR INVOLVEMENT ON BEHALF OF THE FOUNDATION. ANY VIOLATION OF THE DUTY OF THE DISCLOSURE BY DIRECTORS OR OFFICERS OF THE FOUNDATION IS GROUNDS FOR REMOVAL FROM THE OFFICE. FORM 990, PART VI, SECTION B, LINE 15A THE COO'S COMPENSATION IS REVEIWED AND APPROVED BY THE COMPENSATION COMMITTEE. THE MEMBERS OF THE ENTIRE GOVERNING BODY MAKE UP THE COMPENSATION COMMITTEE. THE ORGANIZATION USES AN INDEPENDENT CONSULTANT TO GATHER COMPARABILITY DATA AND PROVIDE ADDITIONAL ANALYSIS. THE COMPENSATION COMMITTEE DOCUMENTS ITS DELIBERATIONS IN THE GOVERNING BOARD MINUTES AND ESTABLISHES A WRITTEN CONTRACT. THIS PROCESS TAKES PLACE ANNUALLY. THE HR DIRECTOR OVERSEES THE SALARY PROGRAM FOR ALL OTHER EMPLOYEES. FORM 990, PART VI, SECTION C, LINE 19 THE GOVERNING DOCUMENTS, FINANCIAL STATEMENTS AND CONFLICT OF INTEREST POLICY ARE MADE AVAILABLE TO THE PUBLIC UPON REQUEST. VOLUNTEER BOARD OF DIRECTORS: PART VII THE BOARD OF DIRECTORS ARE NOT COMPENSATED FOR THEIR SERVICES AS THE BOARD OF DIRECTORS. COMPENSATION REPORTED TO BOARD MEMBERS ON PART VII IS RELATED TO COMPENSATION FOR SERVICES AS EMPLOYEES AND ER PHYSICIANS. AVERAGE HOURS PER WEEK REPORTED FOR EACH BOARD MEMBER IS AN ESTIMATE OF TIME SPENT SOLELY ON BOARD OF DIRECTOR DUTIES. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: ASSETS TRANSFERRED FROM PRAIRIE HEALTH SERVICES, INC UPON MERGER 55,494. FINANCIAL STATEMENTS AUDIT OVERSIGHT: FORM 990, PART XII, LINE 2C: THERE WERE NO CHANGES IN THE PROCESS DURING THE YEAR. VOLUNTEERS: FORM 990, PART I, LINE 6: VOLUNTEERS CONTRIBUTE BY WORKING IN THE GIFT SHOP, TRANSPORTING PATIENTS AND RESIDENTS OF THE COMPLEX TO/FROM APPOINTMENTS AND ASSIST WITH RESIDENT ACTIVITIES IN THE NURSING HOME AND ASSISTED LIVING FACILITY. EXPLANATION OF COMPENSATION - MICHAEL J. MCLAUGHLIN FORM 990, PART VII, SECTION A, LINE 1A & SCHEDULE J, PART II, LINE 1 MICHAEL J. MCLAUGHLIN RECEIVED COMPENSATION FROM THE HOPEDALE MEDICAL FOUNDATION FOR CONSULTING SERVICES PROVIDED TO THE ORGANIZATION. THIS COMPENSATION IS REPORTED TO HIM ON IRS FORM 1099-MISC, AND THE AMOUNT IS INCLUDED IN REPORTABLE COMPENSATION ON FORM 990, PART VII, SECTION A, LINE 1, COLUMN D AND SCHEDULE J, PART II, LINE 1, COLUMN B(III). MISS MONA'S LLC 107 TREMONT STREET HOPEDALE IL 61747 DAY CARE IL 131970 28976 HOPEDALE REAL ESTATE SERVICES INC PRAIRIE HEALTH SERVICES INC PO BOX 267 HOPEDALE IL 61747 371390103 PROMOTE PUBLIC HEALTH AND WELFARE IL 501(C)(3) PF HOPEDALE RURAL HEALTH ASSOCIATION INC 1 HOPEDALE RURAL ASOCIATION INC PO BOX 267 HOPEDALE IL 61747 391930105 SUPPORT HEALTHCARE, EDUCATION AND RESEARCH IL 501(C)(3) PF N/A 0 HOPEDALE REAL ESTATE SERVICES INC 107 TREMONT STREET HOPEDALE IL 61747 371406582 PROPERTY RENTAL IL N/A C 1 0 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 HOPEDALE REAL ESTATE SERVICES INC B 60000 FAIR MARKET VALUE HOPEDALE RURAL HEALTH ASSOCIATION INC S 15916601 FAIR MARKET VALUE PRAIRIE HELATH SERVICES INC S 55494 FAIR MARKET VALUE PART V, LINE 2: EFFECTIVE JUNE 25, 2013, HOPEDALE RURAL HEALTH ASSOCIATION, INC. (HEALTH ASSOCIATION) AND PRAIRIE HEALTH SERVICES, INC. (PHS) EACH MERGED INTO THE HOPEDALE MEDICAL FOUNDATION (FOUNDATION) AND THEN THE HEALTH ASSOCIATION AND PHS DISSOLVED, AT WHICH TIME HOPEDALE REAL ESTATE SERVICES, INC. (HRES) BECAME A WHOLLY-OWNED SUBSIDIARY OF THE FOUNDATION. AS OF JUNE 30, 2013, THE ORGANIZATION CONSISTS OF THE FOUNDATION AND ITS WHOLLY-OWNED SUBSIDIARY, HRES.