2013-07-09T16:06:17-05:00 2012-09-30 390758449 WIPFLI LLP 10000 INNOVATION DRIVE SUITE 250 MILWAUKEE WI 532264837 990 2011-10-01 370661230 PASSAVANT MEMORIAL AREA HOSPITAL ASSOC PASS 2172459541 1600 WEST WALNUT JACKSONVILLE IL 62650 DAVID BOLEN 2172459541 2013-07-09 1 JAY ADKISSON CPA P01360892 4144319300 2013-07-08 2011 2016-03-07 17:11:31Z CHESTER WYNN 1600 WEST WALNUT JACKSONVILLE IL 62650 87847368 0 X WWW.PASSAVANTHOSPITAL.COM X 1906 IL OUR MISSION IS TO PROVIDE EXCELLENT CARE WITH COMPASSION AND COMMITMENT. 16 14 975 203 179606 85612 209902 1437107 82649387 81724489 1997283 2647096 1662265 1972691 86518837 87781383 28770 16617 0 0 43679570 43979625 0 0 21472 35084372 32605503 78792712 76601745 7726125 11179638 151532337 169211387 47837408 47051773 103694929 122159614 OUR MISSION IS TO PROVIDE EXCELLENT CARE WITH COMPASSION AND COMMITMENT. 0 0 61150358 16617 81724489 DELIVERY OF MEDICAL AND HOSPITAL SERVICES WITH APPROXIMATELY 55,666 OUTPATIENT PROCEDURES PERFORMED, 3,290 INPATIENT ADMISSIONS AND 28,905 EMERGENCY DEPARTMENT VISITS. 61150358 1 1 0 1 0 0 0 0 0 1 1 0 0 1 0 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 0 0 0 0 0 0 0 1 1 1 0 0 1 78 0 1 975 1 1 1 0 0 0 0 0 0 0 0 0 X 16 14 0 0 0 0 0 1 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 IL X DAVID BOLEN 2172459541 1600 WEST WALNUT STREET JACKSONVILLE IL 62650 X GINNY FANNING 2.00 X X 0 0 0 JAN TERRY 2.00 X X 0 0 0 DONALD HEADEN 2.00 X X 0 0 0 GILBERT JOEHL 2.00 X X 0 0 0 KEITH BRADBURY 2.00 X X 0 0 0 RICHARD JOHNSON 2.00 X 0 0 0 STEVEN LILLPOP MD 2.00 X 12000 0 0 GREG MAY 2.00 X 0 0 0 NANCY SPANGENBERG 2.00 X 0 0 0 MICHAEL MOLYNEAUX MD 2.00 X 0 237609 47561 REG BENTON 2.00 X 0 0 0 GREG LEPPER 2.00 X 0 0 0 ERIC GIEBENHAUSEN MD 2.00 X 0 0 0 GARY SCOTT 2.00 X 0 0 0 TOM VEITH 2.00 X 0 0 0 PHYLLIS LAPE PHD 2.00 X 0 0 0 CHESTER A WYNN 50.00 X 246815 0 35970 DAVID A BOLEN 50.00 X 178517 0 23814 KAREN DAUM 50.00 X 128618 0 28351 STEPHEN LEE 50.00 X 127117 0 28350 REBECCA GOODMAN 50.00 X 95256 0 18656 MARK RUFF 40.00 X 307559 0 37075 DAVID C TONRY 40.00 X 250738 0 36288 JOHN D GREGORY 40.00 X 240602 0 35568 DEBORAH K TOMKO 40.00 X 192503 0 23858 TAMARA C MCDONALD 40.00 X 226395 0 34462 2006120 237609 349953 24 0 1 0 JOHN C DAILEY MDSC 1572 CONCORD ROAD JACKSONVILLE IL 62650 PHYSICIAN SERVICES 543640 NHEED BASHIR MD 1440 WEST WALNUT JACKSONVILLE IL 62650 PHYSICIAN SERVICES 299276 SPI HEALTHCARE 2960 PROFESSIONAL DRIVE SPRINGFIELD IL 62703 BILLING SERVICE 269290 CENTURION INVESTIGATORS INC 1711 SOUTH WEST ST JACKSONVILLE IL 62650 SECURITY 182289 BKD LLP 211 N BROADWAY SUITE 600 ST LOUIS MO 63102 ACCOUNTING SERVICES 116983 5 1437107 1437107 PATIENT SERVICE REVENU 621110 81350986 81350986 BAD DEBT RECOVERY 900099 373503 373503 81724489 2712281 2712281 639851 0 639851 639851 639851 800 40958 25027 -40958 -24227 -65185 -65185 CAFETERIA 722100 580125 580125 OTHER 900099 573109 573109 LIFE LINE 812900 179606 179606 1332840 87781383 81724489 179606 4440181 16617 16617 911464 729536 181928 31260321 25020761 6239560 1560264 1248835 311429 7822433 6261075 1561358 2425143 1941084 484059 122754 122754 61909 61909 2934008 2348380 585628 366807 293592 73215 11923167 9543303 2379864 388197 310713 77484 1349873 1080438 269435 87488 70025 17463 1564480 1252210 312270 6121865 4899941 1221924 1490085 1192664 297421 REPAIRS AND MAINTENANCE 2994748 2396996 597752 MEDICAID TAXES 1099546 880077 219469 FOOD 1024400 819930 204470 MISCELLANEOUS EXPENSE 606704 468416 116816 21472 469472 375765 93707 76601745 61150358 15429915 21472 5679 5635 7219733 7532508 13197978 15467679 14769284 19284702 687856 746200 1816047 1608437 130348299 81619515 50586028 48728784 44937260 54539334 642227 732983 17670245 20565125 151532337 169211387 18133283 17147986 29704125 29903787 47837408 47051773 X 86275019 101678675 743592 723036 16676318 19757903 103694929 122159614 151532337 169211387 X 11179638 7285047 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 26523 0 0 0 26523 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: 27% OF ILLINOIS HOSPITAL ASSOCIATION MEMBERSHIP DUES ARE ALLOCABLE TO LOBBYING ACTIVITIES. 58899464 10026577 478582 68447459 58790267 1821901 1712704 58899464 66023041 50000 2714136 9996910 58790267 0.68000 0.25000 0.07000 0 0 242737 242737 85701307 51634140 34067167 38705419 27258691 11446728 5698836 2726684 2972152 48728784 BENEFICIAL INTERESTS IN TRUSTS 16991019 OTHER ASSETS 475497 FARMLAND 3098609 20565125 87781383 76601745 11179638 4331132 2953915 7285047 18464685 96957375 4331132 4844860 9175992 87781383 0 87781383 86189579 9587834 9587834 76601745 0 76601745 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE ORGANIZATION INTENDS TO USE THE ENDOWMENT FUNDS FOR CAPITAL PURCHASES, OPERATIONS, SCHOLARSHIPS, AND INDIGENT CARE. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: IN ORDER TO ACCOUNT FOR ANY UNCERTAIN TAX POSITIONS, THE ASSOCIATION DETERMINES WHETHER IT IS MORE LIKELY THAN NOT THAT A TAX POSITION WILL BE SUSTAINED UPON EXAMINATION ON THE TECHNICAL MERITS OF THE POSITION ASSUMING THE TAXING AUTHORITY HAS FULL KNOWLEDGE OF ALL INFORMATION. IF THE TAX POSITION DOES NOT MEET THE MORE-LIKELY-THAN-NOT RECOGNITION THRESHOLD, THE BENEFIT OF THAT POSITION IS NOT RECOGNIZED IN THE FINANCIAL STATEMENTS. THE ASSOCIATION RECORDED NO ASSETS OR LIABILITIES FOR UNCERTAIN TAX POSITIONS IN 2012 OR 2011 AS MANAGEMENT BELIEVES THE ASSOCIATION HAS NO MATERIAL UNRECOGNIZED INCOME TAX POSITIONS. FEDERAL TAX RETURNS FOR TAX YEARS 2008 AND BEYOND REMAIN SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE. PART XI, LINE 8 - OTHER ADJUSTMENTS: CHANGE IN BOND INTEREST RATE SWAP -107,114. CHANGE IN BENEFICIAL INTEREST IN PERPETUAL TRUSTS 3,081,585. DECREASE IN TEMP RESTRICTED ASSETS -20,556. TOTAL TO SCHEDULE D, PART XI, LINE 8: 2,953,915. PART XII, LINE 2D - OTHER ADJUSTMENTS: PASSAVANT PHYSICIAN MEMORIAL HOSPITAL REVENUE 3,425,524. JACKSONVILLE CRNAS REVENUE 1,419,336. PART XIII, LINE 2D - OTHER ADJUSTMENTS: PASSAVANT PHYSICIAN MEMORIAL HOSPITAL EXPENSES 6,174,293. JACKSONVILLE CRNAS EXPENSES 3,413,541. 1 1 1 X 1 X 1 1 1 0 1 1 4831434 4831434 0.06310 10381951 8851359 1530592 0.02000 15213385 8851359 6362026 0.08310 204291 204291 0.00270 15675 15675 0.00020 219966 219966 0.00290 15433351 8851359 6581992 0.08600 413043 413043 0.00540 9685 9685 0.00010 422728 422728 0.00550 1 11616 0 20772257 27585949 -6813692 X 1 1 1 1 PASSAVANT MEMORIAL AREA HOSPITAL

1600 WEST WALNUT ST JACKSONVILLE IL 62650

X X X X PASSAVANT MEMORIAL AREA HOSPITAL 1 0 1 1 200.000000000000 1 350.000000000000 0 1 1 X X X 1 X X 1 X X X X X 1 X 0 1 PART I, L7 COL(F): THE ASSOCIATION 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.FOR THE YEAR ENDED SEPTEMBER 30, 2012 THE ASSOCIATION IS REPORTING A BAD DEBT RECOVERY AND THEREFORE NO ADJUSTMENT IS NEEDED FOR BAD DEBT EXPENSE. PART II: PAH EXPANDED THE EMERGENCY DEPARTMENT TO SERVE AN INCREASING NUMBER OF PATIENTS. THE HOSPITAL'S PANDEMIC FLU COMMITTEE WORKED WITH THE COMMUNITY PANDEMIC TASK FORCE TO PUT A PLAN IN PLACE TO HANDLE H1N1 FLU. PAH HAS RECEIVED TRACTS OF FARM LAND, THE INCOME FROM WHICH ASSISTS WITH NURSING SCHOLARSHIPS AND WITH PATIENTS WHO CAN'T AFFORD TO PAY. WE FARM THE LAND AS THE DONORS HAVE REQUESTED. PAH IS ASSOCIATED WITH THE MORGAN-SCOTT VOLUNTEER HEALTH CLINIC IN AN EFFORT TO ASSIST THOSE WHO ARE UNINSURED. PAH DONATES OFFICE SPACE, LAB AND IMAGING SERVICES PLUS OTHER SERVICES AND CARE TO ELIGIBLE PERSONS THROUGH THE "FREE CLINIC" (MORGAN-SCOTT VOLUNTEER HEALTH CLINIC). PAH OFFERS FREE MAMMOGRAM SCREENINGS AS PART OF ITS ASSOCIATION WITH THE MIA WARE FOUNDATION. THIS FOUNDATION DONATED FUNDS TOWARDS THE PURCHASE OF DIGITAL MAMMOGRAPHY EQUIPMENT AT PASSAVANT. REGARDLESS OF ABILITY TO PAY, NO ONE NEEDING PASSAVANT'S SERVICES IS TURNED AWAY. HEALTH EDUCATION PROGRAMS AND FREE SCREENINGS ARE AVAILABLE TO THE COMMUNITIES THE HOSPITAL SERVES (I.E. PROSTRATE SCREENINGS, COLORECTAL SCREENINGS, DIABETES CLASSES, THE KIDNEY MOBILE, "WALKING FOR WELLNESS" PROGRAM, "COMMUNITY HEALTH CHECK", PROGRAMS ON HEART DISEASE, STROKES, BREAST CANCER, ETC.) PAH, THE MIA WARE FOUNDATION AND THE JACKSONVILLE CHAMBER OF COMMERCE SPONSOR A COMMUNITY HEALTH FAIR EACH YEAR CALLED "THE BE AWARE WELLNESS FAIR." THIS FAIR TAKES PLACE AT COMMUNITY PARK AND PROVIDES PREVENTATIVE HEALTH INFORMATION FOR ALL AGES AND ALSO EMPHASIZES BREAST CANCER AWARENESS. IT'S AN EVENT FOR EVERYONE IN THE FAMILY. PAH ALSO PROVIDES FREE PROGRAMS FOR SCHOOL AGE CHILDREN. SECOND-GRADE CHILDREN COME TO THE HOSPITAL TO ATTEND MINI-MEDICAL DAYS, WHERE INFORMATION IS PRESENTED TO HELP THEM UNDERSTAND WHAT THEY MIGHT ENCOUNTER IF THEY HAVE TO VISIT THE EMERGENCY DEPARTMENT, HAVE BLOOD WORK, HAVE X-RAYS, ETC. SIXTH GRADE STUDENTS ARE INVITED TO GO THROUGH THE "FANTASTIC BODY VOYAGE." THIS PROGRAM TAKES THEM ON A JOURNEY THROUGH THE HUMAN BODY AND LETS THEM EXPLORE VARIOUS BODY SYSTEMS IN A FUN AND EDUCATIONAL WAY. PAH PARTICIPATES IN THE COMMUNITY CHILDHOOD WELLNESS COALITION. RECOGNIZING THE HEALTH OF OUR CHILDREN IS AT RISK FOR MANY HEALTH PROBLEMS BECAUSE OF OBESITY, THE COALITION WORKS TO CREATE AWARENESS, EDUCATION AND PROGRAMS DEVOTED TO PHYSICAL FITNESS, NUTRITION AND WEIGHT MANAGEMENT FOR CHILDREN, AND THEIR PARENTS. IN 2011, A COMMUNITY GARDEN WAS PLANTED ON LAND DONATED BY AN ILLINOIS COLLEGE PROFESSOR. STUDENTS PLANTED AND MAINTAINED THE GARDEN AND THE HARVEST WAS AVAILABLE TO ANYONE INTERESTED. PART III, LINE 8: THE AMOUNT REPORTED ON LINE 6 WAS OBTAINED FOR THE MEDICARE COST REPORT FILED BY THE ORGANIZATION. ALTHOUGH THE AMOUNT ON LINE 7 HAS NOT BEEN INCLUDED IN PART I, LINE 7, THE AMOUNT SHOULD BE TREATED AS A COMMUNITY BENEFIT BECAUSE IT REPRESENTS CARE TO MEMBERS OF THE COMMUNITY WHICH HAS NOT BEEN REIMBURSED TO THE ORGANIZATION. PART III, LINE 9B: OUR COLLECTION POLICY STATES "HOSPITAL MAY PURSUE COLLECTION ACTIVITY ONLY AFTER THE HOSPITAL HAS GIVEN THE PATIENT THE OPPORTUNITY TO APPLY FOR FINANCIAL ASSISTANCE". OUR FINANCIAL ASSISTANCE POLICY STATES "THERE ARE INSTANCES WHEN A PATIENT MAY APPEAR ELIGIBLE FOR CHARITY CARE DISCOUNTS, BUT THERE IS NO FINANCIAL ASSISTANCE FORM ON FILE DUE TO LACK OF SUPPORTING DOCUMENTATION. OFTEN THERE IS ADEQUATE INFORMATION PROVIDED BY THE PATIENT OR THROUGH OTHER SOURCES, WHICH SHOWS SUFFICIENT EVIDENCE TO PROVIDE THE PATIENT WITH CHARITY CARE ASSISTANCE. IF THERE IS NO EVIDENCE TO SUPPORT A PATIENT'S ELIGIBILITY FOR CHARITY CARE, THE HOSPITAL CAN USE OUTSIDE AGENCIES IN DETERMINING ESTIMATED INCOME AMOUNTS FOR THE BASIS OF DETERMINING CHARITY CARE ELIGIBILITY AND POTENTIAL DISCOUNT AMOUNTS. ONCE DETERMINED, DUE TO THE INHERENT NATURE OF THE PRESUMPTIVE CIRCUMSTANCES, THE ONLY DISCOUNT THAT CAN BE GRANTED IS A 100% WRITE OFF OF THE ACCOUNT BALANCE. PRESUMPTIVE ELIGIBILITY MAY BE DETERMINED ON THE BASIS OF INDIVIDUAL LIFE CIRCUMSTANCES THAT MAY INCLUDE 1) STATE-FUNDED PRESCRIPTION PROGRAMS; 2) HOMELESS OR RECEIVED CARE FROM A HOMELESS CLINIC; 3) PARTICIPATION IN WOMEN, INFANTS AND CHILDREN'S PROGRAMS (WIC); 4) FOOD STAMP ELIGIBILITY; 5) SUBSIDIZED SCHOOL LUNCH PROGRAM ELIGIBILITY; 6) ELIGIBILITY FOR OTHER STATE OR LOCAL ASSISTANCE PROGRAMS THAT ARE UNFUNDED (E.G., MEDICAID SPEND-DOWN); 7) LOW INCOME/SUBSIDIZED HOUSING IS PROVIDED AS A VALID ADDRESS; AND 8) PATIENT IS DECEASED WITH NO KNOWN ESTATE." PASSAVANT MEMORIAL AREA HOSPITAL PART V, SECTION B, LINE 13G: ALL STATEMENTS TO THE PATIENT INDICATE OUR FINANCIAL ASSISTANCE CONTACT INFORMATION. INFORMATION IS ALSO LISTED ON THE CONSENT FOR TREATMENT FORM. PASSAVANT MEMORIAL AREA HOSPITAL PART V, SECTION B, LINE 19D: AMOUNT PROVIDED BY ATTORNEY GENERAL STATE OF ILLINOIS HOSPITAL UNINSURED PATIENT DISCOUNT ACT. PASSAVANT MEMORIAL AREA HOSPITAL PART V, SECTION B, LINE 21: PATIENTS ARE CHARGED THE GROSS CHARGE AND THEN THE UNINSURED PATIENT DISCOUNT IS APPLIED. THE REMAINING AMOUNT OF THE BILL IS THEN ELIGIBLE FOR FINANCIAL ASSISTANCE, UNDER THE FINANCIAL ASSISTANCE POLICY. PART VI, LINE 2: 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, FULTON, PIKE, AND CALHOUN COUNTIES. OVER 90% OF CASES COMES FROM THE PRIMARY MARKET. PART VI, LINE 5: PAH EMPLOYEES ARE VOLUNTEERS IN NON-PROFIT ORGANIZATIONS, SUCH AS ROTARY CLUB, KIWANIS, CHAMBER OF COMMERCE, HABITAT FOR HUMANITY, ETC. THEY ALSO SUPPORT THE UNITED WAY AND PARTICIPATE IN THE AMERICAN CANCER SOCIETY'S RELAY FOR LIFE. PAH PROVIDES CASH AND IN-KIND DONATIONS TO AREA NON-PROFIT ORGANIZATIONS AND TO AREA SCHOOLS' POST-PROM PARTIES. PAH ALSO PROVIDES DISEASE-RELATED SUPPORT GROUPS, FREE COMMUNITY HEALTH PROGRAMS AND SCREENINGS, USE OF MEETING ROOMS, CHAPLAIN SERVICES AND LANGUAGE ASSISTANCE SERVICES. WITH THE SUPPORT GROUPS, PAH STAFF FACILITATES SOME OF THOSE GROUPS. PAH PROVIDES FREE MEDICARE CONSULTING SERVICES TO SENIORS. PAH PROMOTES AND SUPPORTS THE JACKSONVILLE AREA SENIOR CENTER, WHICH OFFERS MANY ACTIVITIES FOR SENIORS. PASSAVANT PROVIDES SPEAKERS, SCREENINGS AND HEALTH FAIRS FOR FREE AT THE CENTER. IT ALSO CONDUCTS A "COMMUNITY HEALTH CHECK" AT THE CENTER THE FIRST WEDNESDAY OF EACH MONTH. IN FISCAL YEAR 2012, PAH PROVIDED $11.6 MILLION IN CHARITY CARE AND BAD DEBT CHARGES PLUS $915,000 OF FREE CHARGES AT THE VOLUNTEER HEALTH CLINIC (TOTALING $12.5 MILLION) 1 ILLINOIS HOSPITAL RESEARCH AND EDUCATIONAL ASSOCIATION 1151 EAST WARRENVILLE ROAD NAPERVILLE IL 60566 237421930 501(C)(3) 16617 0 TO ADDRESS THE DISPARATE AND NEGATIVE EFFECTS OF THE ILLINOIS MEDICAID PROGRAM EXPERIENCED BY HOSPITALS AND HEALTHCARE SYSTEMS IN ILLINOIS. 1 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, 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. X X X 0 0 0 0 0 0 0 0 0 MICHAEL MOLYNEAUX MD 0 237609 0 0 0 0 0 11911 0 35650 0 285170 0 0 CHESTER A WYNN 246815 0 0 0 0 0 14700 0 21270 0 282785 0 0 0 DAVID A BOLEN 178517 0 0 0 0 0 5456 0 18358 0 202331 0 0 0 KAREN DAUM 128618 0 0 0 0 0 7836 0 20515 0 156969 0 0 0 STEPHEN LEE 127117 0 0 0 0 0 7836 0 20514 0 155467 0 0 0 MARK RUFF 307559 0 0 0 0 0 15625 0 21450 0 344634 0 0 0 DAVID C TONRY 250738 0 0 0 0 0 15185 0 21103 0 287026 0 0 0 JOHN D GREGORY 240602 0 0 0 0 0 14490 0 21078 0 276170 0 0 0 DEBORAH K TOMKO 192503 0 0 0 0 0 10575 0 13283 0 216361 0 0 0 TAMARA C MCDONALD 226395 0 0 0 0 0 13500 0 20962 0 260857 0 0 0 CITY OF JACKSONVILLE IL 376001700 469590AB9 2006-12-01 12485000 FUNDING FOR CONSTRUCTION AND DEVELOPMENT 0 0 0 CITY OF JACKSONVILLE IL 376001700 469590AA1 2006-12-01 19905000 ADVANCE REFUNDING AND DEFEASANCE OF PREVIOUS BORROWINGS 0 0 0 1815000 12485000 173127 27560 12843313 2007 0 0 0 1 2530000 19905000 276018 43940 806055 2007 0 1 1 1 0 0 0 0 0.00000 0.00000 0.00000 1 0 0 0 0 0.00000 0.00000 0.00000 1 0 1 1 MORGAN STANLEY 24.000000000000 0 0 0 0 0 0 1 1 MORGAN STANLEY 22.000000000000 0 0 0 0 0 FORM 990, PART VI, SECTION A, LINE 7A REPRESENTATIVES OF 139 CHURCHES IN THE PASSAVANT SERVICE AREA MAKE UP THE BOARD OF GOVERNORS. THE BOARD OF DIRECTORS IS ELECTED BY THE BOARD OF GOVERNORS AT THE GOVERNORS' ANNUAL MEETING. FORM 990, PART VI, SECTION B, LINE 11 A COPY OF THE FORM 990 IS REVIEWED BY THE CEO AND THE CFO PRIOR TO FILING. A COPY OF THE FORM 990 IS PROVIDED TO THE BOARD FOR REVIEW PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C BOARD MEMBERS AND KEY EMPLOYEES ARE REQUIRED TO DISCLOSE CONFLICTS OF INTERESTS 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 ORGANIZATION'S SALARY FOR A POSITION AND ASSOCIATED MINIMUM, 1ST QUARTILE, MIDPOINT, 3RD QUARTILE AND MAXIMUM SALARY POINTS. THE KEY EMPLOYEE DATA IS REVIEWED BY OUR CEO, 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 AVAILABLE UPON INDIVIDUAL REQUEST. THE AUDITED FINANCIAL STATEMENTS ARE POSTED ON THE HOSPITAL'S WEBSITE. COMPENSATION PAID BY RELATED ORGANIZATIONS: FORM 990, PART VII: COMPENSATION DR. MOLYNEAUX EARNED WAGES AS A PHYSICIAN AT PASSAVANT PHYSICIAN ASSOCIATION, A RELATED ORGANIZATION, AND WORKED ON AVERAGE 40 HOURS PER WEEK RELATED TO THIS POSITION. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 4,331,132. CHANGE IN BOND INTEREST RATE SWAP -107,114. CHANGE IN BENEFICIAL INTEREST IN PERPETUAL TRUSTS 3,081,585. DECREASE IN TEMP RESTRICTED ASSETS -20,556. TOTAL TO FORM 990, PART XI, LINE 5: 7,285,047. 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