2013-08-13T13:33:58-05:00 2012-12-31 351178661 BLUE & CO LLC ONE AMERICAN SQUARE 2200 INDIANAPOLIS IN 46282 990 2012-01-01 356067049 MARGARET MARY COMMUNITY HOSPITAL INC MARG 8129346624 321 MITCHELL AVENUE BATESVILLE IN 470060226 BRIAN DAEGER 8129346624 2013-08-13 1 AMBER KOCHER CPA P01286298 3176334705 2012 2016-02-24 21:20:13Z BRIAN DAEGER 321 MITCHELL AVENUE BATESVILLE IN 470060226 96604146 0 X WWW.MMCH.ORG X 1967 IN IMPROVE THE HEALTH OF THE COMMUNITIES IT SERVES. 14 12 657 54 0 0 480972 182692 71736916 74251748 1193195 3327456 608935 384832 74020018 78146728 38000 121247 0 0 33499846 37004633 0 0 0 33330144 30890963 66867990 68016843 7152028 10129885 111889864 126447819 44747545 46383768 67142319 80064051 X IMPROVE THE HEALTH OF THE COMMUNITIES IT SERVES. 0 0 1168778 56211 COMMUNITY HEALTH SERVICES- 68,443 INDIVIDUALS TOOK PART IN SERVICES AND PROGRAMS SUCH AS CANCER SCREENINGS, CPR AND AED TRAINING, DIABETES CARE, FLU CLINICS, NUTRITION CLASSES, SMOKING CESSATION SUPPORT, BLOOD PRESSURE AND THYROID SCREENINGS, WOMEN'S HEALTH EVENTS, OSTEOPOROSIS SCREENINGS, WELLNESS SCREENINGS, EMERGENCY PREPAREDNESS, AND HEALTH INSURANCE ENROLLMENT AND REFERRALS. 1875999 0 SUBSIDIZED HEALTH SERVICES - 28,094 INDIVIDUALS RECEIVED BENEFITS FROM OUR HOSPITAL OWNED OUTPATIENT SERVICES. THIS INCLUDES OSGOOD PHYSICIAN PRACTICE LOCATED IN A RURAL AREA AND IS ALSO LOCATED IN A MEDICALLY UNDERSERVED AREA. 234702 4540 FINANCIAL AND IN-KIND CONTRIBUTIONS - 2,851 INDIVIDUALS HAVE RECEIVED BENEFITS FROM OUR EMS AND PARAMEDIC TRAINING AND SUBSIDY PROGRAMS. MMCH SUBSIDIZES A PORTION OF THE RIPLEY COUNTY PARAMEDIC/EMS DIRECTOR'S SALARY. MMCH ALSO COORDINATES AND SUBSIDIZES TRAINING FOR THE 4 RIPLEY COUNTY SQUADS LOCATED IN VERSAILLES, SUNMAN, MILAN, AND BATESVILLE. IN ADDITION, VARIOUS MMCH TEAM MEMBERS SERVE ON NUMEROUS COMMUNITY BOARDS INCLUDING MARCH OF DIMES, RELAY FOR LIFE, AND THE BATESVILLE COORDINATED SCHOOL HEALTH BOARD. 56404136 121247 74338917 3,545 INDIVIDUALS HAVE TAKEN PART IN ADDITIONAL PROGRAMS AND SERVICES PROVIDED BY MMCH, INCLUDING CAREER AND WORKFORCE DEVELOPMENT FOR PHYSICIAN, NURSING, AND OTHER MEDICAL STUDENTS THROUGH OUR MENTORING PROGRAMS AND CAREER FAIRS. IN ADDITION, MMCH IS INVOLVED IN CLINICAL RESEARCH AT THE HANSEN CENTER, A CANCER TREATMENT CENTER OWNED AND OPERATED BY MMCH IN BATESVILLE. VARIOUS COMMUNITY NEEDS/HEALTH ASSESSMENTS ALSO TAKE PLACE ON A CONTINUOUS BASIS. 56404136 121247 74338917 59683615 1 1 0 1 0 0 0 0 0 1 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 111 0 1 657 1 0 0 0 0 0 1 1 0 0 0 0 X 14 12 0 0 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 1 0 IN X TOM WALKER ACCOUNTING MANAGER 8129346624 321 MITCHELL AVENUE BATESVILLE IN 470060226 TIMOTHY PUTNAM 40.00 X X 286456 0 39990 JOHN DICKEY 2.00 X 0 0 0 MARK GIESTING 2.00 X 0 0 0 JEFFREY HATCHER MD 40.00 X 442560 0 58191 GEORGE JUNKER 2.00 X 0 0 0 DONALD KARBOWSKI 2.00 X 0 0 0 RONALD KNUEVEN 2.00 X 0 0 0 CINDY LAUBER 2.00 X 0 0 0 JIM ROBERTS 2.00 X 0 0 0 SAM ROW 2.00 X 0 0 0 JAN SANTERRE 2.00 X 0 0 0 CHRIS TRAINOR 2.00 X 0 0 0 MARY ANN WISE-CASTNER 2.00 X 0 0 0 STEVE YOUNGMAN 2.00 X 0 0 0 BRIAN DAEGER 40.00 X 206301 0 35450 JULIE KEENE 40.00 X 137379 0 32498 BONNIE PLOEGER 40.00 X 135701 0 21997 NANCY MARTICKE 40.00 X 206653 0 36675 KIM INSCHO 40.00 X 174145 0 34320 BRIAN ALBERS MD 40.00 X 363580 0 59144 KIMBERLY KICK MD 40.00 X 249524 0 36759 THOMAS BROWN MD 40.00 X 378093 0 38991 JON GEERS MD 40.00 X 410662 0 30077 CHARLES MCGOVER MD 40.00 X 258429 0 38604 3249483 0 462696 34 0 1 0 MIDWEST EMERGENCY DEPT SERVICES 320 EAST HIGHWAY 50 OFALLON IL 62269 EMERGENCY ROOM PHYSICIAN STAFFING SERVIC 1489327 BLUE & CO ONE AMERICAN SQUARE 2200 INDIANAPOLIS IN 46282 CPA SERVICES 315422 SOUTH BEND MEDICAL FOUNDATION 530 N LAFAYETTE BLVD SOUTH BEND IN 46601 LAB SERVICES 261668 DR ROBERTSON 102 CROSSTIE LANE BATESVILLE IN 47006 MEDICAL SERVICES FOR PATIENTS 164412 HALL RENDER KILLIAN 39778 TREASURY CENTER CHICAGO IL 60694 LEGAL SERVICES 119255 5 5670 72000 105022 182692 NET PATIENT SERVICE RE 621110 74251748 74251748 74251748 1726459 1726459 147920 0 147920 147920 147920 20038105 20310 18417866 39552 1620239 -19242 1600997 1600997 0 5670 0 0 2225 0 2225 2225 CAFETERIA 900099 219613 219613 MISCELLANEOUS 900099 9502 9502 VENDING 900099 5572 5572 234687 78146728 74399668 0 3564368 X 84247 84247 37000 37000 1146634 1005977 140657 26775037 23490568 3284469 676082 593148 82934 6506207 5708097 798110 1900673 1667519 233154 8386763 7357967 1028796 236121 207156 28965 9510479 8343837 1166642 1454282 1275887 178395 348061 305365 42696 200547 175946 24601 1380698 1211329 169369 5470329 4799289 671040 669623 587481 82142 OTHER EXP 3018717 2643875 374842 DUES & SUB. 215343 188927 26416 68016843 59683615 8333228 0 13845347 7209794 7086953 7551507 948755 987074 616076 827139 110720334 54718992 51330282 56001342 36228694 52389387 1833757 1481576 111889864 126447819 6216701 7955417 33782073 32632804 4748771 5795547 44747545 46383768 X 67047592 80004520 94727 59531 67142319 80064051 111889864 126447819 10129885 2791847 0 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 4694 4694 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: PORTION OF ANNUAL DUES PAID TO TRADE ASSOCIATIONS ALLOCATED TO LOBBYING. 42898171 5530932 6085391 112443 54402051 44740699 3183091 -1255562 3770057 42898171 28745024 12087147 3997487 35690 53269 44740699 28185363 79491 585756 105586 28745024 21243317 63435 6993987 115376 28185363 0.99890 0.00000 0.00110 0 0 2371158 2371158 70747317 29764573 40982744 37490258 24954419 12535839 111601 111601 56001342 DERIVATIVE LIABILITY 3311447 ESTIMATED THIRD-PARTY SETTLEMENT 2484100 5795547 X 80938575 2738693 53154 2791847 78146728 0 78146728 68016843 0 68016843 0 68016843 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE ASSETS WHOSE USE IS LIMITED ARE ASSETS WHOSE USE IS LIMITED BY INTERNAL BOARD DESIGNATION INCLUDING CASH AND CASH EQUIVALENTS, ACCRUED INTEREST RECEIVABLE, AND MARKET SECURITIES WHICH ARE BEING USED FOR CAPITAL IMPROVEMENTS, RETIREMENT PLAN, AND FOR DEBT SERVICE PAYMENTS. TEMPORARILY RESTRICTED NET ASSESTS ARE THE FUNDS WHOSE USE HAS BEEN LIMITED BY EXTERANAL SOURCES FOR A SPECIFIC TIME PERIOD OR PURPOSE WHICH ARE BEING USED FOR SCHOLARSHIPS AND OTHER HOSPITAL PROGRAMS. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: FOOTNOTE TO THE ORGANIZATION'S FINANCIAL STATEMENTS THAT REPORTS THE ORGANIZATION'S LIABILITY FOR UNCERTAIN TAX POSITIONS UNDER FIN 48 SUPERSEDED BY FASB ACCOUNTING STANDARD CODIFICATION 740-10: ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA REQUIRE MANAGEMENT TO EVALUATE TAX POSITIONS TAKEN BY THE HOSPITAL AND RECOGNIZE A TAX LIABILITY IF THE HOSPITAL HAS TAKEN AN UNCERTAIN POSITION THAT MORE LIKELY THAN NOT WOULD NOT BE SUSTAINED UPON EXAMINATION BY VARIOUS FEDERAL AND STATE TAXING AUTHORITIES. MANAGEMENT HAS ANALYZED THE TAX POSITIONS TAKEN BY THE HOSPITAL, AND HAS CONCLUDED THAT AS OF DECEMBER 31, 2012 AND 2011, THERE ARE NO UNCERTAIN POSITIONS TAKEN OR EXPECTED TO BE TAKEN THAT WOULD REQUIRE RECOGNITION OF A LIABILITY OR DISCLOSURE IN THE ACCOMPANYING FINANCIAL STATEMENTS. THE HOSPITAL IS SUBJECT TO ROUTINE AUDITS BY TAXING JURISDICTIONS; HOWEVER, THERE ARE CURRENTLY NO AUDITS FOR ANY TAX PERIODS IN PROGRESS. PART XI, LINE 2D - OTHER ADJUSTMENTS: UNREALIZED LOSS ON DERIVATIVES 53,154. 1 1 1 X 275.000000000000 1 X 275.000000000000 1 1 1 0 1 1 1628 765786 765786 0.01130 4598000 2509000 2089000 0.03070 1628 5363786 2509000 2854786 0.04200 42 69117 1430773 59686 1371087 0.02020 5 2426 249378 249378 0.00370 2 28094 1875999 1875999 0.02760 1 1 100045 100045 0.00150 11 2851 234702 4540 230162 0.00340 61 102489 3890897 64226 3826671 0.05640 61 104117 9254683 2573226 6681457 0.09840 1 4 9227 9227 0.00010 1 345 1736 1736 0.00000 1 17 2136 2136 0.00000 3 753 45783 45783 0.00070 6 1119 58882 58882 0.00080 0 6533475 0 12836391 17207130 -4370739 X 1 0 1 1 MARGARET MARY COMMUNITY HOSPITAL

321 MITCHELL AVENUE BATESVILLE IN 47006

WWW.MMCH.ORG X X X X MARGARET MARY COMMUNITY HOSPITAL 1 1 1 275.000000000000 1 275.000000000000 1 X X X X X X 1 1 X X X X X X 1 0 1 X 0 0 4 THE HANSEN CENTER

6 PINE RANCH RD BATESVILLE IN 47006

CANCER TREATMENT CENTER OUTPATIENT REHABILITATION CENTER

STATE RD 129 BATESVILLE IN 47006

THERAPY & ORTHOPEDIC CENTER OCCUPATIONAL HEALTH CLINIC

374 NORTHSIDE DR SUITE D BATESVILLE IN 47006

CLINIC WELLNESS CLINIC

4 W PEARL ST BATESVILLE IN 47006

CLINIC PART I, LINE 3C: FOR ELIGIBILITY GUIDELINES A SLIDING SCALE IS USED FOR DISCOUNTED CARE IF THE PATIENT IS OVER OUR 275% FEDERAL POVERTY GUIDELINES. PART I, LINE 7: THE COST TO CHARGE RATIO METHOD WAS USED TO CALCULATE THE CHARITY CARE AND CERTAIN OTHER COMMUNITY BENEFITS AT COST. PART I, LINE 7G: N/A - ORGANIZATION DOES NOT INCLUDE ANY COST ATTRIBUTABLE TO A PHYSICIAN CLINIC IN THE SUBSIDIZED HEALTH SERVICES COSTS. PART I, L7 COL(F): TOTAL BAD DEBT EXPENSE OF $0 INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A) HAS BEEN EXCLUDED FROM THE DENOMINATOR FOR THE PERCENTAGE CALCULATION PER IRS INSTRUCTION. EFFECTIVE WITH THE ADOPTION OF ASU 2011-07, THE STANDARD REQUIRES CERTAIN HEALTHCARE ENTITIES TO PRESENT THE PROVISION FOR BAD DEBT RELATING TO PATIENT SERVICE REVENUE AS A DEDUCTION FROM PATIENT SERVICE REVENUE. SEE EXPLANATION OF FINANCIAL STATEMENT FOOTNOTE DISCLOSURE FOR PART III, LINE 4. PART II: MMCH SUPPORTS COMMUNITY BUILDING BY PARTICIPATING AND BEING AN ACTIVE PARTNER IN EMERGENCY PREPAREDNESS. MMCH PROMOTES BUILDING THE FUTURE OF HEALTHCARE BY DEVELOPING MENTOR AND CAREER DEVELOPMENT PROGRAMS IN THE HEALTHCARE FIELD. MMCH ALSO HAS A RECRUITMENT PLAN TO ENSURE ACCESS TO THE MEDICAL CARE. PART III, LINE 4: SECTION A, LINE 2 EXPLANATION: AUDITED FINANCIAL STATEMENT FOOTNOTE 1 SIGNIFICANT ACCOUNT POLICIES: EFFECTIVE JANUARY 1, 2012, THE HOSPITAL ADOPTED ASU 2011-07, HEALTHCARE ENTITIES (TOPIC 954), "PRESENTATION AND DISCLOSURE OF PATIENT SERVICE REVENUE, PROVISION FOR BAD DEBTS, AND THE ALLOWANCE FOR DOUBTFUL ACCOUNTS FOR CERTAIN HEALTHCARE ENTITIES," WHICH REQUIRES CERTAIN HEALTHCARE ENTITIES TO PRESENT THE PROVISION FOR BAD DEBTS RELATING TO PATIENT SERVICE REVENUE AS A DEDUCTION FROM PATIENT SERVICE REVENUE IN THE CONSOLIDATED STATEMENTS OF OPERATIONS RATHER THAN AS AN OPERATING EXPENSE. ALL PERIODS PRESENTED HAVE BEEN RECLASSIFIED TO CONFORM TO THIS PRESENTATION. THE HOSPITAL'S ADOPTION OF THIS STANDARD HAD NO NET IMPACT ON ITS FINANCIAL POSITION, RESULTS OF OPERATIONS, OR CASH FLOWS. ASU 2011-07 ALSO REQUIRES HEALTHCARE ENTITIES TO PROVIDE ENHANCED DISCLOSURE ABOUT THEIR POLICIES FOR RECOGNIZING REVENUE AND ASSESSING BAD DEBTS, AS WELL AS QUALITATIVE AND QUANTITATIVE INFORMATION ABOUT CHANGES IN THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS. SEE THE "PATIENT ACCOUNTS RECEIVABLE", "ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS" AND "PATIENT SERVICE REVENUE" SECTIONS OF THIS NOTE. [ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS] PATIENT ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS BASED ON THE HOSPITAL'S EVALUATION OF ITS MAJOR PAYOR SOURCES OF REVENUE, THE AGING OF THE ACCOUNTS, HISTORICAL LOSSES, CURRENT ECONOMIC CONDITIONS, AND OTHER FACTORS UNIQUE TO ITS SERVICE AREA AND THE HEALTHCARE INDUSTRY. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THE MAJOR PAYOR SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE HOSPITAL ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS AND A PROVISION FOR BAD DEBTS, IF NECESSARY. FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PAYMENTS, WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL, THE HOSPITAL RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES IF NEGOTIATED) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS. DURING 2012, THE HOSPITAL'S ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS CHANGED APPROXIMATELY $388,000 FROM $4,552,000 TO $4,940,000. THE UNCOLLECTIBLE ALLOWANCE FOR SELF PAY BALANCES INCREASED APPROXIMATELY $76,000 AS THE UNCOLLECTIBLE ESTIMATE INCREASED TO 97% OF SELF PAY BALANCES FROM 93% AT DECEMBER 31, 2011. THE UNCOLLECTIBLE ALLOWANCE FOR THIRD PARTY PAYOR ACCOUNTS INCREASED APPROXIMATELY $312,000 AS THE UNCOLLECTIBLE ESTIMATE INCREASED TO 5% OF THIRD PARTY PAYOR BALANCES FROM 3% AT DECEMBER 31, 2011. IN ADDITION, THE HOSPITAL'S SELF PAY RELATED WRITEOFFS INCREASED BY APPROXIMATELY $208,000 TO $6,533,000 IN 2012 FROM $6,325,000 IN 2011. THE INCREASES WERE THE RESULT OF NEGATIVE TRENDS EXPERIENCED IN THE COLLECTION OF AMOUNTS FROM SELF PAY PATIENTS IN 2012. THE HOSPITAL DID NOT CHANGE ITS CHARITY CARE OR UNINSURED DISCOUNT POLICIES DURING 2012 OR 2011. AS OF DECEMBER 31, 2012, THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS OF APPROXIMATELY $4,940,000 WAS COMPRISED OF $4,473,000 RESERVED FOR SELF-PAY BALANCES AND $467,000 RESERVED FOR THIRD-PARTY PAYOR BALANCES. AS OF DECEMBER 31, 2011, THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS OF APPROXIMATELY $4,552,000 WAS COMPRISED OF $4,398,000 RESERVED FOR SELF-PAY BALANCES AND $154,000 RESERVED FOR THIRD-PARTY PAYOR BALANCES.PART III, LINE 4, SECTION A, LINE 3 EXPLANATION: NO OTHER BAD DEBT AMOUNTS HAVE BEEN INCLUDED AS COMMUNITY BENEFIT. THE HOSPITAL HAS A DETAILED FINANCIAL ASSISTANCE POLICY WHICH STATES THAT TO PARTICIPATE IN CHARITY CARE, CANDIDATES MUST COOPERATE FULLY. 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. 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 DECEMBER 31, 2012 REPORT: HOSPITAL STATEMENT OF REIMBURSABLE COST. MARGARET MARY COMMUNITY HOSPITAL PART V, SECTION B, LINE 10: FOR ELIGIBILITY GUIDELINES A SLIDING SCALE IS USED FOR DISCOUNTED CARE IF THE PATIENT IS OVER OUR 275% FEDERAL POVERTY GUIDELINES. MARGARET MARY COMMUNITY HOSPITAL PART V, SECTION B, LINE 20D: CHARGES ARE APPLIED TO ALL ACCOUNTS AT THE TIME OF SERVICES, REGARDLESS OF WHETHER THE PATIENT IS COVERED BY INSURANCE OR NOT. ONCE INDIVIDUALS ARE DETERMINED TO MEET THE FINANCIAL ASSISTANCE POLICY REQUIREMENTS DISCOUNTS ARE APPLIED. PART VI, LINE 2: MMCH COMPLETES A COMMUNITY HEALTH ASSESSMENT EVERY 3 TO 5 YEARS WHICH INCLUDES FOCUS GROUPS WITH LOCAL PARTNERS AND LEADERS. PART VI, LINE 3: MMCH INFORMS AND EDUCATES PATIENTS AND PERSONS ABOUT ELIGIBILITY FOR ASSISTANCE WITH POSTED SIGNAGE IN ALL REGISTRATION AREAS AND ON OUR WEBSITE. PART VI, LINE 4: MMCH SERVES A PRIMARY AND SECONDARY MARKET THAT INCLUDED RIPLEY, FRANKLIN, AND DECATUR COUNTIES. THIS IS PRIMARILY A RURAL COMMUNITY. PART VI, LINE 5: MMCH IS GOVERNED BY A COMMUNITY BOARD. MMCH OPERATES A 24 HOUR EMERGENCY ROOM. MMCH COMPLETES A COMMUNITY ASSESSMENT AND A PLAN TO ADDRESS OUR COMMUNITY NEEDS. PART VI, LINE 6: N/A - THE ORGANIZATION IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM.PART VI, LINE 8: LIST OF STATES RECEIVING COMMUNITY BENEFIT REPORT: INDIANA 1 MARGARET MARY HEALTH FOUNDATION 321 MITCHELL AVE BATESVILLE IN 47006 455039355 501C3 84247 IN-KIND EXPENSES PAID TO ASSIST WITH START-UP OF THE FOUNDATION. 1 0 SCHOLARSHIPS, SEVEN RECIPIENTS RECEIVED $1,000 AND TEN RECIPIENTS RECEIVED $3,000. 17 37000 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: ASSISTANCE TO ORGANIZATIONS: ALL GRANTS ARE PROVIDED TO 501(C)(3) PUBLIC CHARITIES FOR GENERAL SUPPORT. MARGARET MARY COMMUNITY HOSPITAL DOES NOT MONITOR THE USE OF THESE FUNDS BY THESE PUBLIC CHARITIES. CURRENT YEAR SUPPORT WAS FOR EXPENSES PAID TO ASSIST IN SETTING UP MARGARET MARY HEALTH FOUNDATION. ASSISTANCE TO INDIVIDUALS: SCHOLARSHIP APPLICATIONS ARE REVIEWED BY SENIOR MANAGERS AND A HUMAN RESOURCE REPRESENTATIVE. CRITERIA REVIEWED INCLUDE GPA, DEGREE PURSUING, YEAR THEY WOULD GRADUATE AND THE NEED OF MMCH. TO RECEIVE FUTURE INSTALLMENTS STUDENT MUST MAINTAIN MINIMUM 3.0 GPA AND PROVIDE A COPY OF TRANSCRIPTS. X X X X 0 0 0 0 0 0 0 0 0 TIMOTHY PUTNAM 286456 0 0 0 0 0 8594 0 31396 0 326446 0 0 0 JEFFREY HATCHER MD 442560 0 0 0 0 0 22350 0 35841 0 500751 0 0 0 BRIAN DAEGER 206301 0 0 0 0 0 6189 0 29261 0 241751 0 0 0 JULIE KEENE 137379 0 0 0 0 0 4121 0 28377 0 169877 0 0 0 BONNIE PLOEGER 135701 0 0 0 0 0 4071 0 17926 0 157698 0 0 0 NANCY MARTICKE 206653 0 0 0 0 0 6200 0 30475 0 243328 0 0 0 KIM INSCHO 174145 0 0 0 0 0 5224 0 29096 0 208465 0 0 0 BRIAN ALBERS MD 363580 0 0 0 0 0 22350 0 36794 0 422724 0 0 0 KIMBERLY KICK MD 249524 0 0 0 0 0 6977 0 29782 0 286283 0 0 0 THOMAS BROWN MD 378093 0 0 0 0 0 5410 0 33581 0 417084 0 0 0 JON GEERS MD 410662 0 0 0 0 0 0 0 30077 0 440739 0 0 0 CHARLES MCGOVER MD 258429 0 0 0 0 0 7753 0 30851 0 297033 0 0 0 SUPPLEMENTAL INFORMATION PART III MR. PUTNAM AND DR. HATCHER SERVE AS BOARD MEMBERS AND ARE EMPLOYEES OF MARGARET MARY COMMUNITY HOSPITAL. THEIR HOURS AND COMPENSATION DOCUMENTED ON THE FORM 990, PART VII AND SCHEDULE J RELATE THEIR DUTIES AS EMPLOYEES OF THE HOSPITAL. A INDIANA HEALTH FACILITY FINANCING AUTHORITY 351611409 454798PAL 2004-04-01 22000000 FINANCE ONCOLOGY AND OUTPATIENT CENTERS 0 0 0 B INDIANA FINANCE AUTHORITY 351602316 2010-12-16 16625235 REFINANCE 2008 BONDS AND FINANCE 28,000 SQUARE FEET MEDICAL OFFICE BUILDING. 0 0 0 A 22000000 264000 21736000 2004 0 0 1 1 B 16625235 379878 16625 3162004 8625235 4821371 2012 0 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 B 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 A 0 0 1 0 1 1 PIPER JAFFRAY FINANCIAL PRODUCTS 25.000000000000 0 0 0 0 1 B 0 0 1 0 1 0 0 0 1 A 1 B 1 FORM 990, PART VI, SECTION A, LINE 6 THE ORGANIZATION HAS MEMBERS. ALL ADULT RESIDENTS OF THE AREA SERVED BY MARGARET MARY COMMUNITY HOSPITAL SHALL BE ELIGIBLE FOR MEMBERSHIP IN THE ORGANIZATION. ANY SUCH RESIDENT MAY BECOME A MEMBER BY PAYMENT OF THE ANNUAL MEMBERSHIP FEE PROVIDED FOR IN THE BY-LAWS OF THE ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 7A EACH MEMBER WHOSE CURRENT ANNUAL MEMBERSHIP HAS BEEN PAID AT LEAST TEN DAYS IN ADVANCE OF ANY MEETING SHALL BE ENTITLED TO ONE VOTE AT ANY MEETING OF THE MEMBERS. THE MEMBERS OF THE ORGANIZATION ELECT THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION B, LINE 11 THE PROCESS OF REVIEWING THE FORM 990 ENTAILS A DETAILED REVIEW BY THE ORGANIZATION'S ACCOUNTING DEPARTMENT. THE FORM 990 IS THEN PRESENTED AND REVIEWED WITH THE FINANCE COMMITTEE. ONCE APPROVED BY THE FINANCE COMMITTEE, THE GOVERNING BODY RECEIVES AN ELECTRONIC COPY OF THE FORM 990 INCLUDING REQUESTED SCHEDULES, AS ULTIMATELY FILED WITH THE IRS, FOR REVIEW AND APPROVAL PRIOR TO FILING WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C THE WRITTEN CONFLICT OF INTEREST POLICY IS REGULARLY AND CONSISTENTLY MONITORED AND COMPLIANCE ENFORCED BY BRIAN DAEGER, MMCH CORPORATE COMPLIANCE OFFICER. THE SCOPE OF THIS POLICY INCLUDES ALL BOARD AND FINANCE COMMITTEE MEMBERS, SENIOR MANAGEMENT OF MMCH, AND ANY PHYSICIAN WHO HOLDS A MEDICAL DIRECTORSHIP POSITION AT MMCH. THE POLICY IS IN PLACE TO IDENTIFY AND APPROPRIATELY DEAL WITH A CONFLICT OF INTEREST SITUATION THAT MAY EXIST. THE COVERED PERSONS ARE TO REFRAIN FROM TRANSACTIONS THAT COULD POTENTIALLY CREATE A CONFLICT OF INTEREST. A SELF DISCLOSURE FROM COVERED PERSONS TO BRIAN DAEGER, MMCH CORPORATE COMPLIANCE OFFICER, IS REQUIRED ON ANY POTENTIAL CONFLICTS OF INTEREST. DEPENDING ON THE TYPE OF CONFLICT OF INTEREST, THE COVERED PERSON WOULD NOT PARTICIPATE IN ANY DELIBERATION OR DECISIONS ON SUCH TRANSACTIONS. THIS WOULD INCLUDE ABSTAINING FROM VOTING ON CERTAIN MATTERS. BRIAN DAEGER, MMCH CORPORATE COMPLIANCE OFFICER, IS RESPONSIBLE FOR REVIEWING AND RESEARCHING THE CONFLICTS DISCLOSED. FORM 990, PART VI, SECTION B, LINE 15 CEO COMPENSATION DETERMINED BY BOARD. THE BOARD THOROUGHLY REVIEWED COMPENSATION INFORMATION AND HIRED OUTSIDE CONSULTANTS TO ADVISE APPROPRIATE SALARY RANGES. OTHER OFFICERS OR KEY EMPLOYEES COMPENSATION IS DETERMINED BY CEO. FORM 990, PART VI, SECTION C, LINE 19 THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THE PUBLIC UPON REQUEST. OTHER FEES FORM 990, PART IX, LINE 11G CONTRACT LABOR/TEMPORARY SERVICES : PROGRAM SERVICE EXPENSES 4,508,849. MANAGEMENT AND GENERAL EXPENSES 1,028,796. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 5,537,645. PROFESSIONAL FEES - MEDICAL : PROGRAM SERVICE EXPENSES 2,849,118. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,849,118. OVERSIGHT OF AUDIT THE FINANCE COMMITTEE OF THE BOARD OF DIRECTORS ASSUMES RESPONSIBILITY FOR THE OVERSIGHT OF THE AUDIT OF THE FINANCIAL STATEMENTS AND NO PROCESSES HAVE CHANGED FROM THE PRIOR YEAR. MARGARET MARY HEALTH FOUNDATION 321 MITCHELL AVE BATESVILLE IN 47006 455039355 FUNDRAISING IN PENDING 501C3 LINE 11A, I MARGARET MARY COMMUNITY HOSPITAL INC 1 0 1 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 MARGARET MARY HEALTH FOUNDATION B 82248 EXPENSES INCURRED